Checklist to Identify the Gaps in Quality Improvement of ...

Checklist to Identify the Gaps in QualityImprovement of Secondary Hospitals

with Higher Services

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Executive Summary

Minimum Service Standards (MSS) for hospitals is the service readiness and availability of tool for optimal requirement of the hospitals to provide minimum services that are expected from them. This tool entails for preparation of service provision and elements of service utilization that are deterministic towards functionality of hospital to enable working environment for providers and provide resources for quality health service provision. MSS for hospitals reflect the optimally needed minimum criteria for services to be provide but in itself is not an “ideal” list of the maximum standards. This checklist of MSS is different than a program specific quality improvement tool as it will outline the equipment, supplies, furniture, human resource required for carrying out service but not detail out the standards operating procedures of any service.

The results of Nepal Health Facility Survey 2015 showed that among the health facilities that were assessed only 13 percent of them had all seven basic equipment items- adult weighing scale, child weighing scale, infant weighing scale, thermometer, stethoscope, blood pressure apparatus and a light source for service provision. The availability of all supplies and equipments defined for standard precaution control was as low as 0.2%, all basic laboratory services in 12% and only 3% facilities had client feedback mechanism in place. This was an alarming situation. During that period, minimum service standards was rolled out in 83 district level hospitals and was evident to contribute in quality of services provided by hospitals with instances of improved governance, management, clinical and support services. This encouraged MoHP to put on its efforts on setting the minimum service standards for hospitals secondary and tertiary levels and at the same time contextual revision of MSS for district hospitals to set MSS for primary level hospitals. The revision and development of the tool took into series of steps beginning with formulation of Technical Working Group and selection of subject experts and technical coordinator and consultative workshops and meetings (Figure: Process of MSS revision and development). The key guiding documents are Constitution of Nepal 2072, National Health Policy 2014, Policy on Quality Assurance in Health Care Services, 2064, Public Health Service Act 2075, Nepal Integrated Health Infrastructure Development Standards 2073/74, Nepal Health Sector Strategy 2015-2020 and Guideline on Health Institution Establishment, Operation and Upgrading Standards, 2070 but not limited to them.

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Figure Process of Revision and Development of Minimum Service Standards for Hospitals

Thus prepared MSS is a comprehensive tool for optimal preparation of the hospitals for the minimum services that are needed to be provided by these health facilities and has potential to bring a positive change. The health sector needs are dynamic and revision of the services and standards in due course is anticipated. The revision of MSS for hospitals is planned to be done every 2-3 years (completion of cycle of MSS in all targeted government hospitals) to incorporate the learning and adapt the documents to the emerging context.

The MSS tool has been organized in three major sections: Governance and Management, Clinical Service Management and Hospital Support Service Management. It has been prepared in the form of checklist that thrives for the preparedness and utilization that are fundamental to establish services towards quality. For secondary hospitals, there are 1063 set of standards with total score of 1343, out of which- 104 standards for measuring governance and management and has weightage of 20%, 819 standards for measuring clinical service management and has weightage of 60%, and 138 standards for measuring support service management and has weightage of 20%. Governance and management section includes the minimum standards for six subsections, clinical service management has twenty one sub sections and hospital support service management has eleven subsections.

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After assessment of all the sections of the standards, for overall scoring, each section is then weighed. The section of the governance and management (Section I) is weighed in 20%, that of clinical service management (Section II) is weighed in 60% and that of hospital support service management (Section III) is weighed in 20%. The sum of these weighed percentage of the subsections give the overall MSS score of the hospitals and based on it color code will be provided. This MSS Score for hospitals measure the existing situation and enables to identify the gap areas that are to be addressed through the development of the actions plan that demands both technical and financial inputs and managerial commitments. The overall process is guided by its implementation guideline that describes on sequences of self-assessment and follow up workshops and gap identification for action plan development and striving for optimal MSS Score.

Ministry of Health and Population strives to implement MSS in hospitals for establishing enabling environment at service delivery point through preparedness and availability for quality service provision to the users. Not being an exhaustive list of facilities and services, hospitals are encouraged to strive for betterment and go beyond the defined set of minimum standards whenever their resources support.

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Table of Contents

Executive Summary ....................................................................................................................................... vii

Hospital Identification Sheet ..........................................................................................................................xiii

Background ....................................................................................................................................................1

Introduction ...................................................................................................................................................1

Process of Minimum Service Standards Development ................................................................................3

Organization of the Standards ..................................................................................................................7

How to use this Checklist? .......................................................................................................................8

Section I: Governance and Management Standards .......................................................................................... 11

Summary Sheet of Standards and Scores ................................................................................................. 11

Governance ..........................................................................................................................................12

Organizational Management ..................................................................................................................13

Human Resource Management and Development ...................................................................................14

Financial management ..........................................................................................................................20

Medical Records and Information Management ......................................................................................21

Quality Management ............................................................................................................................22

Section II: Clinical Service Management ..........................................................................................................23

Summary Sheet for Standards and Scores ...............................................................................................23

OPD Service ..........................................................................................................................................24

Special Clinics .......................................................................................................................................35

Hospital Pharmacy Service .....................................................................................................................61

Inpatient Service ...................................................................................................................................64

Maternity Services ................................................................................................................................78

Surgery / Operation Services ..................................................................................................................99

Hemodialysis service ........................................................................................................................... 117

Intensive Care Services ........................................................................................................................123

Diagnostics and laboratory...................................................................................................................132

Postmortem .......................................................................................................................................153

Medico-legal services ..........................................................................................................................155

One stop crisis management center ......................................................................................................157

Physiotherapy (Physical Rehabilitation) .................................................................................................162

Dietetics and Nutrition rehabilitation ....................................................................................................164

Cardiac catheterization Laboratory .......................................................................................................166

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Section III: Hospital Support Services Standards .............................................................................................173

Summary Sheet for Standards and Scores .............................................................................................173

CSSD ..................................................................................................................................................174

Laundry ..............................................................................................................................................176

Housekeeping .....................................................................................................................................178

Repair, Maintenance and Power system ................................................................................................180

Water supply ......................................................................................................................................181

Hospital Waste Management ...............................................................................................................181

Safety and Security .............................................................................................................................182

Transportation and Communication ......................................................................................................184

Store (Medical and Logistics) ................................................................................................................185

Hospital Canteen and Dietetics .............................................................................................................185

Social Service Unit ...............................................................................................................................186

Annex I List of Subject Experts ......................................................................................................................188

List of Reviewers .........................................................................................................................................189

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Hospital Identification Sheet

Name of the Hospital

Assessment Date

Assessed By

1.

2.

3.

Score of Section I: Governance and Management

Score of Section II: Clinical Service Management

Score of Section III: Hospital Support Service Management

Overall MSS Score

MSS Score Color Category

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Background IntroductionMinimum Service Standards (MSS) for hospitals is the service readiness and availability of tool for optimal requirement of the hospitals to provide minimum services that are expected from them. This tool entails for preparation of service provision and elements of service utilization that are deterministic towards functionality of hospital to enable working environment for providers and provide resources for quality health service provision. MSS for hospitals reflect the optimally needed minimum criteria for services to be provide but in itself is not an “ideal” list of the maximum standards. This checklist of MSS is different than a program specific quality improvement tool as it will outline the equipment, supplies, furniture, human resource required for carrying out service but not detail out the standards operating procedures of any service.

The results of Nepal Health Facility Survey 2015 showed that among the health facilities that were assessed only 13 percent of them had all seven basic equipment items- adult weighing scale, child weighing scale, infant weighing scale, thermometer, stethoscope, blood pressure apparatus and a light source for service provision. The inception of minimum service standards started with the realization to improve the curative services in rural hospitals with focus on hospital management. It began as piloting in 4-hospital in 2013 in partnership with Nick Simons Institute to support district hospital for assessment of minimum service standards using “MSS Checklist to Identify the Gaps in Quality Improvement of District Hospitals”. This has been rolled out successfully nationwide in 83 district level hospitals.

The availability of all supplies and equipments defined for standard precaution control was as low as 0.2%, all basic laboratory services in 12% and only 3% facilities had client feedback mechanism in place. This was an alarming situation. During that period, minimum service standards was rolled out in 83 district level hospitals and was evident to contribute in quality of services provided by hospitals with instances of improved governance, management, clinical and support services. This encouraged MoHP to put on its efforts on minimum service standards for hospitals.

Following the learning from the implementation of MSS and considering the current Federal context, MoHP has updated MSS for the district hospitals to make it applicable to Primary Hospitals. At the same time, MoHP has also developed the MSS for secondary and tertiary hospitals in line with the intervention planned in the NHSS-Implementation plan (2016-2021).

In developing the Minimum Service Standards for hospitals, following documents were key references:

1. National Health Policy 2071

2. Policy on Quality Assurance in Health Care Services, 2064

3. Public Health Service Act, 2075

4. Governance (Management and Operation) Act, 2064

5. Financial Procedure Regulation, 2064

6. Nepal Health Service Regulation, 2055

7. Civil Service Regulation, 2050

8. Basic Health Service Package 2075. Ministry of Health and Population, GoN

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9. Nepal Health Sector strategy 2015 -2020. Ministry of Health and Population, GoN.

10. Nepal Integrated Health Infrastructure Development Standards 2073/74

11. Quality Improvement Tool for Health Facility, 2074

12. Guideline on Health Laboratory Establishment and Operation Standards, 2073

13. Implementation Guideline for Social Audit in Health Sector, 2070 Revised 2073

14. Hospital Pharmacy Service Guideline, 2070 Amended 2072

15. National List of Essential medicines 2066/67 Revised 2072/73

16.Minimum Service Standards (MSS) Checklist to Identify the Gaps in Quality Improvement of District Hospitals, Curative Service Division, MoHP, GoN, 2071/72

17. Guideline on Health Institution Establishment, Operation and Upgrading Standards, 2070

18. Transaction Accounting and Budget Control System (TABUCS) Users’ Guide, 2070

19. Guideline for Heath Management Information System, Recording and Reporting, 2070

20.Job Description of Staffs of Regional Health Directorate and District Health and Public Health Offices, 2070

21. Operational Procedure of Department of Health Services, 2068

22. Implementation Guideline Quality Improvement of Health Services, 2066

23. Infection Prevention Reference Manual (District Hospital and Health Facility), 2066

24. National Medical Standard for Reproductive Health, Vol. III, 2063/64

25.National Safe Motherhood and Newborn Health Program District Maternal and Neonatal Health Need Assessment Toolkit Vo. 1, Hospital, 2063/64

26.Health care waste management guideline, 2014. Ministry of Health and Population. Government of Nepal

27. Hospital management practices observed in 83 District and upgraded hospitals.

28.Series of consultation Workshops, Technical Working Group meetings and consultation of subject experts.

Besides these, literature related to health facility readiness and availability, and quality of care were visited by the consultant, technical coordinator, subject experts and TWG members and contextual reality were given priority during the development of the MSS tools.The Minimum Service Standards have been defined considering the existing organizational structure of the hospitals, provision of human resources and financing capacity. The defined standards basically focus on the readiness of hospitals towards ensuring the delivery of quality health services. However, hospitals are encouraged to strive for betterment and go beyond the defined set of minimum standards whenever their resources support. The health sector needs are dynamic and revision of the services and standards in due course is anticipated. The revision of MSS for hospitals is planned to be done every 2-3 years (completion of cycle of MSS in all targeted government hospitals) to incorporate the learning and adapt the documents to the emerging context.

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Process of Minimum Service Standards Development

Formation of Technical Working Group (TWG)

A Technical Working Group was formed by MoHP to develop the Minimum Service Standards (MSS) for Hospitals with involvement of the then curative service division, related sections and departments and experts from the external development partners.

The TWG comprised of the following members as per previous MOHP structure and the members continued till finalization of the document:

• Chief, The then Curative Service Division, MoHP- Coordinator

• Chief, Public Health Administration, The then Monitoring and Evaluation Division, MoHP- Member

• Medical Generalist, MoHP- Member

• Executive Director, Health Insurance Board- Member

• Chief, The then Nursing Section, MoHP- Member

• Under Secretary, The then Curative Service Division, MoHP- Member

• Chief, The then Quality Section of Management Division- Member

• Representative, World Health Organization, Nepal- Member

• Representative, DFID/Nepal Health Sector Support Program- Member

• Representative, Nick Simons Institute- Member

• Section Chief, The then Curative Service Division, MoHP- Member Secretary

Identification of subject experts and technical coordinator

As per the agreement of the TWG members and the learning from MSS implementation in district hospitals, it was agreed to divide the MSS into three sections namely; Governance and Management, Clinical Service Management and Hospital Support Service Management. With series of meetings among the TWG members, subject experts (Annex I- List of Subject Experts) were identified for consultation in specific sections of the service standards under the leadership of the then Curative Service Division. They also developed term of reference for technical coordinator who would be a liaison among MoHP, partners and subject experts for the persecution of the task.

Desk review and template development

Technical coordinator (TC) for the work supported TWG for the development of the templates for revision of the minimum service standards for primary, secondary and tertiary hospitals with desk review of the key guiding documents (as listed in background) and service availability and readiness tool of World Health Organization (WHO). Thus developed templates were shared with the subject experts. All the subject experts were coordinated by TC for preparing the zero draft of the MSS and TWG moved on to the next step of consultative workshops.

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Figure Process of Revision and Development of Minimum Service Standards for Hospitals

Series of coordination meeting between MoHP, TWG and supporting partners

Series of coordination meeting were conducted by MoHP for the discussion of action points with TWG members and supporting partners for MSS. Being based on identified need the consultative workshops, their modality and participants were finalized.

Orientation and consultative workshop

For orientation and consultative workshop, participants were subject experts and consultant doctors, government officials from department, sections and divisions of MoHP, representatives from various academic institutions, different regional, zonal and district level hospitals and partner agencies. There were around 62 participants in the workshop addressed by Health Secretary, MoHP. Subject experts from tertiary center, regional, zonal and district hospitals of the country shared their valuable experience of understating and working for minimum service standards while being part of the district level hospitals during their service. From the workshop, revision of MSS for primary level and development of MSS for secondary and tertiary hospitals was guided to be service oriented leading to a comprehensive practical tool for institutionalizing readiness and

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service availability in the hospitals. Technical coordinator shared the draft one with the TWG team and critical areas for intensive work out identified were- intensive care units, anesthesia, emergency and public health perspective. Being based on the critical areas identified, modality for further steps was contextualized and Review Workshop I was planned with experts for working in identified critical areas.

Draft review and finalization workshop

For review and finalization workshop, there were around 25 participants including members of TWG, government officials from the then Curative Service Division, Management Division, subject experts on intensive care, anesthesia and emergency services from academic institutions, professional bodies and hospitals, and experts from partner agencies. The inputs from the workshop on was on format of tool to arrange the supporting annex immediately followed by standards and sequence of the annexes used along with standards to be uniformly allocated as furniture, equipment, instrument and supplies for making it user friendly. The technical inputs were received in all three thematic areas with special inputs on intensive care, anesthesia and emergency services; also contextualization of the ratio of health workforce for services was done during the workshop. The feedback were incorporated by TC to develop draft second of the MSS. Technical coordinator shared the draft second with the TWG team and draft sharing review workshop II with the professional councils and associations, representatives from central level hospital was planned.

Draft sharing and review workshop

For draft sharing and review workshop, there were around 35 participants who were representatives from Nepal Medical Council, Nepal Nursing Council, executives from central level hospitals, representatives from Nepal Medical Association, Nepal Nursing Association and Society of Public Health Physician Nepal. It was identified during the workshop that there is requirement of division of the clinical service components of primary hospitals at least into two sections of less than 50 beds and 50 beds to 100 beds for the ease of the relevancy of the services available. Also final format for the tool was decided to be addressing- area, its component, verification having the service standards. Being based on the inputs from workshop, separate MSS for primary hospitals with general service and primary hospitals with specialized services were drafted. And additional consultation was done with identified nephrologist, neurologist, gastrologist and burn/plastic surgeon for additional services in tertiary hospitals who were consulted by TC for technical inputs and thus draft third of the MSS was prepared. Closed group workshop with MSS implementers for proof reading and appraisal of practical aspects of the MSS was planned.

Closed group workshop with MSS Implementers

For closed group workshop with MSS implementers, participants were members of TWG, team of implementers working as district health support program officers of partner organization who were working closely with the district hospitals for MSS implementation. In the workshop, each of the standards were reviewed and their practical experiences were shared and documented. The tool was assessed for user-friendliness and inputs were incorporated related to directions of use of the tool was added in places where there were checklists and annexes followed by the standards. Feedback were incorporated by TC to develop draft fourth of the MSS which was presented to TWG. This draft was then used for field testing.

Field Testing of MSS

For field testing, the working team was composed of TWG members and coordinated by TC. Field testing was done in Western Regional Hospital, Pokhara and Syangja District Hospital. The hospital staffs of both the hospitals were given brief presentation by TWG member and further facilitated with help of Hospital Director at Western Regional Hospital and Medical Superintendent at Syangja District Hospital respectively. The department/unit heads were consulted and the tool was thoroughly read by them and marked as agreeable to

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them for assessing the readiness and availability of any services they are giving and asked about its practicable aspects. After incorporation of feedback, final draft were shared by TC with TWG and further shared with sections and department chiefs of MoHP and a consensus development workshop was planned.

Consensus Development Workshop

For consensus development workshop, the working team was composed of TWG members, TC and coordinated by Quality Assurance and Regulation Division (QARD). There were around 35 participants representing the different sections, Department of Health Service, Department of Drug Administration, Department of Ayurveda, and divisions of MoHP, representatives from province health directorate and representatives of partner organization. Consensus was developed in most of the content of the MSS and its implementation guideline was recommended to be in line with the federal context. Feedback received was focused on the practical aspect of the MSS and it was put forward as paving the road towards quality of care. After incorporation of feedback, final tools were shared by TC with TWG and further shared to Health Secretary of MoHP for further approval.

After approval from MoHP, the implementation of the MSS will be guided by "Minimum Service Standards Implementation Guideline 2075”.

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Organization of the Standards

The overall service standards are categorized in three major sections: governance and management, clinical service management and hospital support service management. There are total 1064 set of standards with total score of 1344; with 107 standards for measuring governance and management and score of 111 has a weightage of 20%, 819 standards for measuring clinical service management and score of 1085 has a weightage of 60%, and 138 standards for measuring support service management and score of 148 has a weightage of 20%.

Section I: Governance and management

Strengthening Governance and Management is a key to provide the enabling environment in hospitals for service providers and users. This section includes the minimum standards for the following subsections:

1.1. Governance

1.2. Organizational management

1.3. HR management and development

1.4. Financial management

1.5. Medical records and information management

1.6. Quality Improvement

Section II: Clinical Service Management

In order to ensure quality of care at the point of delivery, the implementation of clinical service standards is essential. This section comprises of minimum standards under the following sub sections:

2.1. Outpatient services (General Medicine, Obstetrics/gynecology, General Surgery, Pediatrics, Orthopedics, Dental, Psychiatry and Ear, Neck and Throat (ENT))

2.2. Special Clinics (Immunization and growth monitoring; family planning; Anti-tubercular treatment (ATT), anti-retroviral treatment (ART), Safe abortion Services)

2.3 Emergency Service

2.4 Emergency Minor OT

2.5 Hospital Pharmacy Service

2.6 Inpatient Service (Medicine Ward, Surgery Ward, Pediatrics Ward, Orthopedics Ward, Psychiatry Ward, ENT Ward, PNC and Gynecology Ward, and Geriatrics Ward)

2.7 Maternity Services (Delivery Service, Maternity Inpatient Ward)

2.8 Surgery/ Operation Service

2.9 Diagnostics and investigations (Laboratory, blood bank, X-ray, USG, ECG, Echocardiogram, Treadmill Test, CT Scan, Endoscopy, Audiometry)

2.10 Hemodailysis

2.11 Intensive Care Services- ICU, PICU, NICU

2.12.1 Postmortem Services

2.12.2 Medico-legal Services

2.13 One Stop Crisis Management Center (OCMC) Services2.14 Physiotherapy2.15 Dietetics and Nutritional Rehabilitation2.16 Cardiac Catheterization Lab

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Section III: Hospital Support Service Management

Implementing the standards for Hospital Support Services is equally important to avail and support delivery of quality clinical services. This section includes minimum standards under the following subsections:

3.1. CSSD

3.2. Laundry

3.3. Housekeeping

3.4. Repair and maintenance, power system

3.5. Water supply

3.6. Hospital Waste Management

3.7. Safety and Security

3.8. Transportation and Communication

3.9. Store (Medical and Logistics)

3.10. Hospital Canteen and dietetics

3.11. Social service unit (SSU)

How to use this Checklist?The MSS for hospitals is a self- assessment tool. Each standard has set of dimensions with one or more verification criteria which is assessed. The checklist enables hospitals to measure the existing situation in through scoring and helps to identify the gap areas to be addressed through the development of the actions plans. This is a cyclical process and its details are explained in the implementation guideline and users’ guide for further understanding of assessment, process of action plan development and follow up of improvement from baseline. The key steps are as follows:

Group discussion

• Conduct a group discussion in your hospital to see if the hospital really meets the given standards under each section.

Filling the checklist

• Read each section carefully and if your hospital meets the given standards, please score from 0 to 3 in the column of the score based on the maximum score for that standard

• For areas where there is indication of checking annex, please calculate the percentage and follow the scoring chart for scoring from 0 to 3

• For areas where there is indication of checking the checklist, please use both the standard and checklist for getting the clear picture of that standard

• Please use individual copies for each department/unit wherever applicable so that there is least biasness in the assessment

• Complete this process for all the standards

Scoring the checklist

• In each sub-section, add the total score and convert it into percentage.• Calculate the average of the percentages obtained in its sub-section to obtain the score of a section• Do this to all three sections to obtain the scores of each section and then take the weightage for

calculating the overall MSS score of the hospital

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Sample of filling the tool

Area CodeVerification

CSSD 3.1

Components Standards Obtained Score

Maximum Score

3.1.1 Space

3.1.1.1 Separate central supply sterile department (CSSD) is available. with running water facility 1 1

3.1.1.2 There are separate rooms/ space allocated for dirty and clean utility. 1 1

3.1.2 Staffing 3.1.2 Separate staffs assigned for CSSD under leadership of trained nursing staff 1 1

3.1.3 Equipment and supplies for CSSD

3.1.3

Equipment and supplies for sterilization available and functional round the clock (See Annex 3.1a CSSD Equipment and Supplies At the end of this standard)

2 3

3.1.4 Preparing consumables 3.1.4 Wrapper, gauze, cotton balls, bandages are

prepared. 1 1

Standard 3.1Total Score 6 7Percentage = Total Score / 7 x 100= 6/7x100 85.7%

Annex3.1a CSSD Equipment and Supplies

SN Items Required No. Score

Working Table 3 1

Trolley for Transportation 2 0

Steel Drums 10 0

Autoclave Machine (250 liter, pre-vacuum, with horizontal outlet) 2 1

Total Score 3

Total Percentage = Total Score/4 X 100 75

Each row gets a score of 1 if all the required number is available otherwise 0.

Scoring Chart

Total Percentage Score

0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard 3.1.3 2

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Weightage of the sections and Overall MSS Score

After assessment of all the sections of the standards, for overall scoring, each section is then weighed. The section of the governance and management (Section I) is weighed in 20%, that of clinical service management (Section II) is weighed in 60% and that of hospital support service management (Section III) is weighed in 20%. For example:

If Section I has the overall score of 80%, Section II has 60% and Section III has 80%; the overall score of the hospital for MSS assessment is calculated as:

Overall MSS Score = (0.2xSectionI + 0.6X Section II + 0.2x Section III)%

Overall MSS Score = (0.2x80%+ 0.6x60%+0.2x 80%)

Overall MSS Score= 68%

Interpretation of the MSS scores

The overall idea of the MSS score is that it is the minimally required optimal readiness of the hospitals to provide the available services. And moving towards the obtaining 100% in all individual sub-sections and overall MSS score is the requirement to thrive a step ahead towards quality service provision. The scores for any sub-sections being less than fifty (<50) is taken as very poor and alarming and needs to be addressed first. The scores from fifty to less than seventy (50 to<70) are taken as the state of improving status that needs specific targeted areas support. The scores from seventy to less than eighty five (70 to <85) indicate acceptance level that requires careful specific interventions. And from eighty five percentages onwards is optimal level of the readiness of the hospitals to provide the available services that requires sustained efforts to maintain the level and move towards 100%.

Overall MSS Score and Color Coding

Being based on the overall MSS score (%) obtained, the color coding of the health facilities will be done as follows:

MSS overall score (%) Color Code

Less than 50 White

50-70 Yellow

70-85 Blue

85-100 Green

In the above example the overall MSS score is 68%, thus health post will be categorized in yellow color zone. It will be provided with the yellow flag as its color code for MSS score.

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Section I: Governance and Management StandardsSummary Sheet of Standards and Scores

AreaTotal Number of Standards

Total ScoreTotal Obtained Score (Percentage)

Governance 27 27

Organizational Management 16 16

Human Resource Management and Development

18 20

Financial Management 17 17

Medical Records and Information Management

14 14

Quality Management 15 17

Total 107 111

Score of Section I

(Average of the percentage obtained = Sum of percentage obtained in each sub-section/ Number of sub-section (6))

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Governance 1.1


Maximum Score

1.1.1 Formation of Hospital Management Committee (HMC)

1.1.1 Hospital Management Committee is formed 1

1.1.2 Capacity building of HMC 1.1.2 All HMC members have received an

orientation on HMC functions 1

1.1.3 Availability of Medical Superintendent

1.1.3 Medical Superintendent is fulfill as per organogram 1

1.1.4 Functional HMC

1.1.4.1

HMC meetings called upon by member secretary / Medical Superintendent headed by chairperson conducted at least 3 times per year or as per need

1

1.1.4.2 HMC meetings have covered at least following agenda (See minutes of last meetings):

1.1.4.2.1 Hospital services and utilization 1

1.1.4.2.2 Hospital’s financial issues 1

1.1.4.2.3Patient rights issues e.g. patient facilities, analysis of complaints received, patient security

1

1.1.4.2.4 Management issues- HR issues, security issues 1

1.1.4.2.5 Infrastructure/ Equipment issues 1

1.1.4.2.6

Coordination issues with local governance- rural municipality/ municipality, provincial, federal, DoHS, MoHP

1

1.1.4.2.7Review of decisions and recommendations of staff meeting and QI Committee meetings discussions

1

1.1.5 Support in health financing

1.1.5.1 Hospital implements health insurance program 1

1.1.5.2All targeted women receive Aama Surakhsya program incentives on time (in last quarter)

1

1.1.6 Annual plan & budget 1.1.6 Annual plan & budget is approved by

HMC before the fiscal year starts 1

1.1.7Storage of HMC documents 1.1.7 There is a separate locker for HMC

documents. 1

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1.1.8 Accountability

1.1.8.1 Updated citizens charter is displayed 1

1.1.8.2 Notices of public concern are displayed publicly 1

1.1.8.3 Complaint boxes are kept in a visible place 1

1.1.8.4Information officer opens complaint box at least once a week and issues are timely addressed

1

1.1.8.5

Hospital has a website or social media account like- Facebook, Viber or Twitter- available and functional with latest information

1

1.1.8.6Hospital has geriatrics friendly infrastructure (like side rails for mobilization and support)

1

1.1.8.7 Hospital has friendly environment for people with disability (like ramps) 1

1.1.9 Grievance and complain handling

1.1.9.1 Mechanism for grievance and complain handling institutionalized 1

1.1.9.2 Grievance and complains are effectively addressed 1

1.1.10 Hospital has operational manual 1.1.10

Hospital has operational manual with clear information on how hospital operates its’ services

1

1.1.11 Hospital produces an Annual Report

1.1.11 Hospital Annual Report is available in website 1

1.1.12 Conduct social audit 1.1.12 Social audit is conducted for last year 1

Standard 1.1Total Obtained Score 27

Percentage = Total Obtained Score / 27 x 100

Area CodeVerification Organizational

Management 1.2


Maximum Score

1.2.1 Organizational structure

1.2.1.1Organogram of hospital showing departments/units with number of staffs is displayed

1

1.2.1.2Organogram of hospital is reviewed every 2 years and forwarded to higher authority

1

1.2.2 Work division and delegation of authorities

1.2.2 Written delegation of authorities is maintained 1

1.2.3 Maintaining client flow system 1.2.3

Navigation chart with services and departments guiding clients to access services

1

1.2.4 Queue system 1.2.4Hospital implements token and / or queue system for users (separate for elderly, disable and pregnant)

1

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1.2.5 E-Attendance 1.2.5 All staffs of hospital use electronic attendance 1

1.2.6 Dress code for all staffs

1.2.6.1All clinical, technical and administrative staffs have apron / uniform which is worn on duty

1

1.2.6.2 All hospital staffs carry personal ID cards when on duty 1

1.2.7 Maintaining effective team work environment

1.2.7.1 Hand-over meetings are conducted daily and also in concerned department 1

1.2.7.2 Morning conference is conducted everyday 1

1.2.7.3 Regular meetings are conducted as follows (see meeting minutes):

1.2.7.3.1 Intra- departmental meeting every two weeks 1

1.2.7.3.2 Inter-departmental meeting once a month 1

1.2.7.3.3 Staff meeting once a month 1

1.2.7.4 Staff quarters are provided and adequate for the staffs 1

1.2.7.5Separate space allocated for breast feeding for staffs/ Separate space in duty room designated for breast feeding

1

1.2.7.6 Transport services for hospital staffs covering all shifts 1

Standard 1.2Total Obtained Score 16Percentage = Total Obtained Score / 16 x 100

Area Code

VerificationHuman Resource Management and Development

1.3


Maximum Score

1.3.1 Personnel administration policy of hospital

1.3.1

Personnel administration guideline of HMC is available (for all staffs including locally hired staff) and practiced accordingly

1

1.3.2 Human resource records 1.3.2

Individual records of all staffs including contract staffs are maintained and updated.

1

1.3.3 Staffing

1.3.3.1

Staffs available for service in hospital as per organogram (See Annex 1.3a Functional Organogram At the end of this standard)

3

1.3.3.2

Maaga Akriti form (dfu cfs[lt kmf/fd) correspondence to fulfill vacant positions to concerned authority as per guideline

1

15

1.3.4 Job description 1.3.4

All staffs including HMC staffs are given a job description when they are recruited/ posted to the hospital (permanent and contract staff)

1

1.3.5 Review of performance 1.3.5.1 Performance appraisal (sf=;=d'=) of all

staffs is done as per guideline 1

1.3.6 Motivating staff and occupational safety

1.3.6.1

A training plan for the hospital is developed based on the training needs of the staff identified at the performance appraisal

1

1.3.6.2For training and related activities, at any point of time, the acceptable work absenteeism is <10% of staff

1

1.3.6.3

There is activity conducted to motivate staff (staff retreat, rewards, recognition of performances, etc.) at least once a year.

1

1.3.6.4Hospital has system for addressing occupational hazard like needle stick injury, radiation exposure, vaccination

1

1.3.7 Continuous professional development (CPD)/ Continuous medical education (CME)

1.3.7.1 Hospital conducts CPD / CME classes to technical staff weekly 1

1.3.7.2Written record of attendance, subjects presented and discussed during CPD/CME

1

1.3.7.3Separate space with furniture, audio-visual aids and internet for CPD/CME/meeting are available.

1

1.3.7.4If hospital is a training site, training guideline of National Health Training Centre is followed

1* (optional)

1.3.8 Library facility available

1.3.8.1 Hospital has its own library with sitting arrangement for readers 1

1.3.8.2

A list of national health guidelines and treatment protocols available and inventory managed for readers accessing it

1

1.3.8.3 Computers with printing and photocopy facility available 1

1.3.8.6

Access to internet facility with institutional access to at least one of the international health related domain like HINARI

1

Standard 1.3Total Score 20


16

Annex 1.3a Functional Organogram for Secondary Hospitals

Functional Organogram for Secondary Hospitals Obtained Score

Maximum Score

For Governance and Management

1. Medical Superintendent 1 1

2. Hospital Management officer 1 1

3. Information officer 1 1

4. Accountant for hospital 1 1

5. Medical recorder 2 1

6. Health Insurance Team As per Health Insurance Board 1

For Clinical Services

7.Doctor: OPD Patients per OPD (Dental service)

1:35-50 (1:20) 1

8. Screening counter

1 paramedics: 4 OPDs and for psychiatry OPD, psychological counselor at least 2, at least one nurse in obstetrics and gynecology OPD

1

9. Special clinics

2 mid-level health workers: 1 Special Clinic*

1*For safe abortion services, at least one trained and certified medical officer/ MDGP/ObGyn for first trimester and second trimester safe abortion services

10. ER beds: Health Workers

5 ER Beds: Doctor (1): Nurse (1): Paramedics (1): Office Assistant (1)

There should be 1:1 nurse patient ratio in red area, 1:3 in yellow area and 1:6 in green area.

1

11.Pharmacy staffs as per pharmacy service guideline 2072

Pharmacy department is lead by at least one clinical pharmacist

1Pharmacy has at least 3 pharmacist, 6 assistant pharmacist and 2 office assistants with monthly duty roster to provide 24 hour service

12. Nursing staff in inpatient per shift per ward

Nurse patient ratio 1:6 in general ward, 1:4 in pediatric ward, 1:2 in high dependency or intermediate ward or post-operative or burn/plastic ward) and at least one trained office assistant/ward attendant per shift in each ward

1

17

13. Nursing staff in labor and maternity per shift

Nurse /SBA trained/midwife mother ratio 1:2 in pre labor; 2:1 per delivery table and 1:6 in post natal ward) with at least one ASBA trained medical officer on duty and one office assistant are available per shift

1

14. Staffing for Hemodialysis

At least one Hemodialysis trained medical officer with on call MD Internal Medicine or Nephrologist

1One haemodialysis trained nurse per two Haemodialysis machine with at least one trained Office assistant in each shift

15. Intensive care service team

One coordinator each for ICU, NICU, PICU with at least MD Anesthesiology, MD Pediatrics respectively with at least one admitting consultant on duty each for ICU, NICU, PICU

1

One trained medical officer for each five bed

Nurse-in-charge one each for ICU, NICU.PICU with nurse patient ratio:

1:1 for ventilated and multi organ failure, 2:3 for ventilated or multi-organ failure and 1:2 for other

Infection Prevention trained office assistant 1 for every five bed and on call biomedical engineer in each shift

16. Nursing supervisor/ administrator

At least three nursing supervisor/administrator (one for IPD, OPD and emergency, one for maternity services, one for intensive care service and Operation Theatre)

1

17. Surgery team per surgery

For one surgery, at least a team is composed of: MS/MDGP with one trained medical officer, two OT trained nurse (one scrub and one circulating), one Anesthesiologist/MDGP, one anesthesia assistant and one office assistant ( for cleaning and helping)

1For overall management of operation theatre, there is one OT nurse (with minimum bachelors degree) assigned as OT in-charge

At least one nurse in pre-anesthesia area for receiving and transferring of the patient

At least two ICU trained nurses for post anesthesia care for receiving patient after OT

18

18. Laboratory

Laboratory team is lead by pathologist (at least) 2 (one for hematology, histopathocytology and biochemistry and 1 for microbiology) with at least 7 lab staffs ( 2 medical technologists, 2 technicians, 1 assistant and 2 helpers are available during routine working hours and on call biomedical engineer.

1

19. X-ray

Adequate numbers of trained healthcare workers are available in x-ray (at least 2 staffs to cover shifts including ER)

1

20. USGUSG trained medical practitioner and mid-level health worker in each USG room

1

21. Echocardiogram

MD internal medicine with echo training or Cardiologist is available for Echo service with at least one mid-level health worker assigned in Echo is available for Echo service with at least one mid-level health worker assigned in Echo

1

22. Treadmill test At least one trained medical officer / cardiologist and one mid-level health worker is allocated for TMT service

1

23. Endoscopy

Physician/ surgeons having endoscopic training or Gastroenterologist or hepatologist or gastrointestinal surgeons with at least 2 Trained endoscopic nurse/paramedic designated for endoscopy room and one trained record keeping staff nurse/paramedics

1

24. Mortuary and medico-legal services

Team led by MD Forensic Medicine with at least one trained medical officer for mortuary service and medico-legal services

1

25. OCMC 2 Staff nurse working in the hospital and 1 trained psycho social counselor 1

26. Physiotherapy

At least 1 physiotherapist trained in Masters in Physiotherapy (MPT), 2 Bachelors’ in Physiotherapy (BPT) and 2 Certificate in physiotherapy (CPT) or Diploma in physiotherapy (DPT) and 1 office assistant

1

19

27.Inpatient and outpatient dietetics and nutritional rehabilitation

one Senior Dietitian (Masters qualification in Nutrition & Dietetics including hospital internship or Bachelors in Nutrition & Dietetics with 1 years hospital experience) plus one dietetic assistant per hundred general beds, plus one office assistant

Additionally, 1 senior dietitian per 25 beds for all specialized services, including ICU, NICU, PICU, nephrology/hemodialysis

1

28. Stabilization center

Inpatient bed: Nurses trained in stabilization of severely undernourished children with complications – 2:1

1

29. Cardiac Catheterization Laboratory

For one cardiac intervention, at least a team is composed of: MD Internal Medicine trained in cardiac intervention or cardiologist with one trained medical officer, two trained nursing/paramedics, and one trained office assistant

1

For Support Services

30. CSSD Separate staffs assigned for CSSD under leadership of trained personal 1

31. Laundry and housekeeping

There is a special schedule for collection and distribution of linens with visible duty roster for staffs laundry and housekeeping

1

32. BMETHuman resource trained in biomedical engineering is designated for repair and maintenance

1

33. Security The hospital has trained security personnel round the clock. 1

34. SSU Facilitators at least 2 to 10 facilitators led by unit chief 1

Total Obtained Score 34

Total Percentage= Total Obtained Score/ 34 x100

Each row gets a score of 1 in each row if it is available otherwise 0.

Scoring Chart

Total percentage Score

0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard 1.3.3

20

Area Code

VerificationFinancial management

1.4


Maximum Score

1.4.1 Account department of hospital

1.4.1.1 Dedicated account department of hospital with space and furniture 1

1.4.1.2 At least one accountant available for hospital financial management 1

1.4.2 Formulation and approval of Annual Hospital Budget

1.4.2.1

An annual hospital budget is developed incorporating the revenue from services, government grants, and support provided by other organizations.

1

1.4.2.2 Internal income is reviewed during budgeting every year. 1

1.4.3 Service fees 1.4.3 The service fees of the hospital are

fixed by HMC every year. 1

1.4.4 Daily income 1.4.4 Daily income is deposited in the bank

every day. 1

1.4.5 Financial review and audit

1.4.5.1 Budget absorption rate of last fiscal year is as per national target 1

1.4.5.2

Internal audit, financial and physical progress review is done at least once each trimester (once in every 4 months).

1

1.4.5.3 Final audit/ external audited accounts are available for last year. 1

1.4.6 Electronic database

1.4.6.1 The hospital uses central electronic billing system 1

1.4.6.2The hospital uses TABUCS/ LMBIS for accounting including local income and expenses by HMC.

1

1.4.7 Hospital prepares financial reports

1.4.7.1 The hospital prepares and keeps monthly financial report. 1

1.4.7.2Trimester financial report is produced (every 4 months) and financial status tracked and discussed in meetings

1

1.4.7.3 Annual financial report is submitted to HMC. 1

1.4.8 Clearing financial irregularities

1.4.8.1 Financial irregularities are responded within 35 days 1

1.4.8.2 Clearance of financial irregularities is done as per national target 1

1.4.9 Inventory inspection 1.4.9 Inventory inspection is done once in a

year and managed accordingly 1



21

Area Code

VerificationMedical Records and Information Management

1.5


Maximum Score

1.5.1 Managing medical records and use of electronic database

1.5.1.1 Client registration is digitized using standard software 1

1.5.1.2Referral in and out records are kept using the standard form (HMIS 1.4) and register.

1

1.5.1.3Electronic health record system that generates the HMIS monthly report (HMIS 9.4)is in place

1

1.5.2 Infrastructure and supplies for information management

1.5.2.1 There is a functional Medical Record Section 1

1.5.2.2 All patients' records are kept in individual folders in racks or held digitally. 1

1.5.2.3There is a set of functional computer and printer available for maintaining medical records.

1

1.5.3 Evidence generation and utilization

1.5.3.1Hospital monthly reports (HMIS 9.4) of the last three months are shared to the national database

1

1.5.3.2

Hospital services utilization statistics are analyzed at least every month and shared with all the HODs and in-charge via email, paper and/or dashboard. (Check last three months status)

1

1.5.3.3

Statistics including OPD morbidity pattern data, IPD data, surveillance data are analyzed and discussed in staff meeting and CPD/CME (Check the status in the last meeting)

1

1.5.3.4Key statistics of service utilization is displayed in respective Departments/ Wards

1

1.5.3.5 Medico-legal incidents and services are recorded 1

1.5.4 Focal person for information management

1.5.4.1 Medical recorder is trained on ICD and DHIS2 1

1.5.4.2An information officer is specified to communicate with patients/clients, their relatives, media and other stakeholders.

1

1.5.4.3Contact details of information officer is displayed in hospital premises with photo and phone number.

1


Percentage = Total Obtained Score / 14x 100

22

Area CodeVerification Quality

Management1.6


Maximum Score

1.6.1 Hospital Quality Health Service Delivery and Management Strengthening (QHSDMS) Committee

1.6.1.1Hospital QHSDMS committee is formed according to MSS Implementation Guideline.

1

1.6.1.2 Hospital QHSDMS committee meetings are held at least every 4 months. 1

1.6.2 Display of patients’ rights and responsibilities

1.6.2The hospital has a statement of patient rights and responsibilities, which is posted in public places in the hospital.

1

1.6.3 Addressing issues in report of social audit

1.6.3The findings of social audit like client exit interview are shared in whole staff meeting

1

1.6.4 Assessing hospital quality 1.6.4

The hospital has assessed the hospital quality using the MSS tool at least every 4 months

1

1.6.5 Planning to improving quality 1.6.5

The hospital has developed specific plans to improve quality based on the MSS assessment.

1

1.6.6 Hospital uses QI tools 1.6.6

Hospital uses QI tools for assessment of the major priority government programs(less than 50%=0, 50-70% =1, 70-85% = 2, 85-100% =3)

3

1.6.7Implementing QI plan

1.6.7.1 Hospital has implemented the specific activities based on the MSS plan. 1

1.6.7.2Hospital has implemented specific activities based on gap analysis of QI tools

1

1.6.8 Clinical Audit

1.6.8.1 The hospital has functional MPDSR committee (in program district) 1

1.6.8.2 There are regular reviews, reporting and dissemination of morbidity and mortality (M&M) including

1.6.8.2.1Investigations and complications of treatment including medication error

1

1.6.8.2.2 Hospital acquired infections (HAI) 1

1.6.8.3 Mortality audit of every death in the hospital is done and reported 1

1.6.8.4Hospital implements Robson’s classification (hospitals with CEONC services)

1

1.6.8.5 Hospital implements baby friendly initiative 1


Percentage = Total Obtained Score/17 x 100

23

Section II: Clinical Service ManagementSummary Sheet for Standards and Scores


Total Score

Total Obtained Score (Percentage)

OPD Service 43 97

Special Clinic 67 73

Emergency Services 38 46

Emergency Operation Theatre (OT) 15 27

Hospital Pharmacy Service 36 40

Inpatient Service 58 154

Delivery Service 34 40

Maternity Inpatient Service (General Ward) 27 33

Birthing Center 31 37

Surgery/Operation Service 44 62

Hemodialysis 38 42

Intensive Care Unit (ICU) 34 40

NICU 35 39

PICU 34 38

Diagnostics and Laboratory Services 170 182

Post-mortem and morturay service 12 14

Medico-legal Services 12 14

One stop crisis management services 23 29

Physiotherapy Services 20 22

Dietetics and Nutrition Rehabilitation 22 22

Cardiac Catheterization Laboratory 28 36

Total 819 1085

Score of Section II


24


OPD Service 1 2.1


Maximum Score

2.1.1 Time for patients

2.1.1.1 OPD is open from 10 AM to 3 PM (See Checklist 2.1 At the end of this standard for scoring). 3

2.1.1.2 Tickets for routine OPD are available till 2 pm 1

2.1.1.3 EHS services from 3PM onwards and tickets available from 2PM onwards 1

2.1.2 Adequate Staffing

2.1.2.1 There should be one administrator to manage all OPDs and procedure room 1

2.1.2.2. Doctor: OPD Patients- 1:35-50 per day for quality of care (*for dental services this ratio is 1:20) 1

2.1.1.2.3One screening counter with 1 paramedics for every four OPDs and there should be one nurse in OB/GYN OPD

1

2.1.3 Maintaining patient privacy

2.1.3

Patient privacy maintained with separate rooms, curtains hung, maintaining queuing of patients with paging system in OPD (See Checklist 2.1 At the end of this standard for scoring).

3

2.1.4 Patient counseling

2.1.4.1

Counseling is provided to patients about the type of treatment being given and its consequences (See Checklist 2.1 At the end of this standard for scoring).

3

2.1.4.2Appropriate IEC materials (posters, leaflets etc.) as an IEC corner available in the OPD waiting area.

1

1 Separate set of sheets for standards, checklist and annexes should be used for assessment of each OPD and cumulative scoring is done after the assessment of all OPDs

25

2.1.5 Physical facilities

2.1.5.1Adequate rooms and space for the practitioners and patients are available (See Checklist 2.1 At the end of this standard for scoring).

3

2.1.5.2Light and ventilation are adequately maintained. (See Checklist 2.1 At the end of this standard for scoring)

3

2.1.5.3 Required furniture, supplies and space are available

2.1.5.3.1General Medicine OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard)

3

2.1.5.3.2Obstetrics and Gynecology OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard)

3

2.1.5.3.3Pediatrics OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard)

3

2.1.5.3.4 Surgery OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard) 3

2.1.5.3.5 Dental OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard) 3

2.1.5.3.6Orthopedics OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard)

3

2.1.5.3.7Psychiatry OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard)

3

2.1.5.3.8 ENT OPD (See Annex 2.1a Furniture and supplies for OPD At the end of this standard) 3

2.1.5.4

Each OPD has designated space/room for procedure room/area with basic supplies of dressing, injection and procedures (specific to OPD like PV for OBGYN, PR for surgery) and hand washing facility (See Checklist 2.1 At the end of this standard for scoring)

3

26

2.1.6 Equipment, instrument and supplies

2.1.6 Equipment, instrument and supplies to carry out the OPD works are available and functioning

2.1.6.1General OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.2Obstetrics and Gynecology OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.3Pediatrics OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.4Surgery OPD(See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.5.1Dental OPD (See Annex 2.1cBasic Equipment and Instrument for Dental OPD At the end of this standard)

3

2.1.6.5.2Dental OPD has fully functioning electric dental chair with adequate light, water supply and drainage system with suction machine

1

2.1.6.5.3 Dental OPD has iopa x-ray machine (along with lead apron and thyroid collar 1

2.1.6.6Orthopedics OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.7Psychiatry OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.6.8ENT OPD (See Annex 2.1b Basic Equipment and Instrument for OPD At the end of this standard)

3

2.1.7 Duty rosters 2.1.7 Duty rosters of all OPDs are developed regularly

and available in appropriate location. 1

2.1.8 Facilities for patients

2.1.8.1Availability of waiting space with sitting arrangement is available for at least 150 persons in waiting lobby (for total OPDs)

1

2.1.8.2 Safe drinking water is available in the waiting lobby throughout the day. 1

2.1.8.3There are at least four toilets with hand-washing facilities (2 for males and 2 for females separate, one each universal toilet)

1

2.1.8.4 Hand-washing facilities are available for patients 1

27

2.1.9 Recording and reporting

2.1.9

OPD register available in every OPD with ICD 10 classification for diagnosis recorded (electronic health recording system) (See checklist 2.1 At the end of this standard for scoring)

3

2.1.10 Infection prevention

2.1.10.1Masks and gloves are available and used (See Checklist 2.1 At the end of this standard for scoring)

3

2.1.10.2

There are well labelled colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP) (See Checklist 2.1 At the end of this standard for scoring)

3

2.1.10.3

Hand-washing facility with running water and soap or hand sanitizer is available for practitioners (See Checklist 2.1 At the end of this standard for scoring)

3

2.1.10.4 Needle cutter is used (See Checklist 2.1 At the end of this standard for scoring) 3

2.1.10.5Chlorine solution is available and utilized for decontamination (See Checklist 2.1 At the end of this standard for scoring).

3


Total Percentage (Total Obtained Score/ 97 x100)

Checklist 2.1 OPD Services(1= General Medicine, 2= Obstetrics/ Gynecology, 3= Pediatrics, 4= General Surgery, 5= Dental, 6= Orthopedics, 7=Psychiatry, 8= ENT)

Code Service StandardsScore

1 2 3 4 5 6 7 8 Total Score Percentage Direction

to use

2.1.1.1 OPD is open from 10 AM to 3 PM*

Go to Standard 2.1.1.2

2.1.3

Appropriate techniques have been used to ensure the patient privacy (separate rooms, curtains hung, maintaining queuing of patients)

Go to Standard 2.1.4

2.1.4.1

Counseling is provided to patients about the type of treatment being given and its consequences


2.1.5.1Adequate rooms and space for the practitioners and patients are available


28

2.1.5.2 Light and ventilation are adequately maintained


2.1.5.4

Each OPD has designated space/room for procedure room/area with basic supplies of dressing, injection and procedures and hand washing facility


2.1.9

OPD register available in every OPD and ICD 10 classification for diagnosis recorded (electronic health recording system)


2.1.10.1 Masks and gloves are available and used


2.1.10.2

There are well labelled colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)


2.1.10.3

Hand-washing facility with running water and soap or hand sanitizer is available for practitioners


2.1.10.4 Needle cutter is used Go to Standard 2.1.10.5

2.1.10.5Chlorine solution is available and utilized for decontamination

Score Standard 2.1

Total percentage = Total score / No. of OPD x 100; Each row gets a score of 1 in each row if is available otherwise 0

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Plot score based on scoring chart in obtained marks of respective standards*Specialized OPDs can be scheduled 2-3 days a week based on available human resource and patients’ flow

29

2.1.5.2 Light and ventilation are adequately maintained


2.1.5.4

Each OPD has designated space/room for procedure room/area with basic supplies of dressing, injection and procedures and hand washing facility


2.1.9

OPD register available in every OPD and ICD 10 classification for diagnosis recorded (electronic health recording system)


2.1.10.1 Masks and gloves are available and used


2.1.10.2

There are well labelled colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)


2.1.10.3

Hand-washing facility with running water and soap or hand sanitizer is available for practitioners


2.1.10.4 Needle cutter is used Go to Standard 2.1.10.5

2.1.10.5Chlorine solution is available and utilized for decontamination

Score Standard 2.1

Total percentage = Total score / No. of OPD x 100; Each row gets a score of 1 in each row if is available otherwise 0

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Plot score based on scoring chart in obtained marks of respective standards*Specialized OPDs can be scheduled 2-3 days a week based on available human resource and patients’ flow

Annex 2.1a Furniture and Supplies for OPD(1= General Medicine, 2= Obstetrics/ Gynecology, 3= Pediatrics, 4= General Surgery, 5= Dental, 6= Orthopedics, 7=Psychiatry, 8= ENT)

SN General Items Required No.Score

1 2 3 4 5 6 7 8

1 Working desk 1 for each practitioner

2 Working Chairs 1 for each practitioner

3 Patient chairs 2 for each working desk

4 Examination table 1 in each OPD room

5 Foot Steps 1 in each OPD room

6 Curtain separator for examination beds In each examination bed

7 Shelves for papers As per need

8 Weighing scale Adult and Child

Total Score

Total Percentage = Total Score/8 X 100

*For psychiatry OPD, furniture should be fixed to prevent harm from violent patients

Each row gets a score of 1 in each row if is available otherwise 0

Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard 2.1.5.3.1








30

Annex 2.1b Basic Equipment and Instruments for OPD(1= General Medicine, 2= Obs/Gyne, 3= Pediatrics, 4= General Surgery, 6= Orthopedics, 7=Psychiatry, 8= ENT)

S.No. Basic equipment and instruments Required No.

Score

1 2 3 4 6 7 8

1. Stethoscope* 1 for each practitioner

2. Sphygmomanometer* (non-mercury) (*Pediatric size in pediatric OPD)

1 for each practitioner

3. Thermometer (digital) 2 in each table

4. Jerk hammer 1 for each practitioner

5. Flash light 1 for each practitioner

6. Disposable wooden tongue depressor As per need

7. Hand sanitizer 1 in each table

8. Examination Gloves As per need

9. X-Ray View Box 1 in each OPD

10. Measuring tape 1 in each table

11. Tuning fork 1 in each table

12. Proctoscope 1

13. Otoscope 1

14. Duck’s Speculum 1

15. Aeyer’s Spatula/ Slides (Pap Smear/ VIA materials) 1

16. Betadine/Swab 1

17. Fetoscope 1

18. Abdominal drape for patient As per need

19. Pediatric Paracetamol At least one syrup

20. Oral Rehydration Solution At least one sachet

21. Goniometer 1 in each table

22. Plaster cutter 1

23. Diagnostic tools for psychiatry 1 set

31

S.No. Basic equipment and instruments Required No.

Score

1 2 3 4 6 7 8

24. Nasal speculum of different size 1 set

25. Bull’s eye lamp 1

26. Head mirror 1 for each practitioner

27. ENT Forceps 1 set

28. Nasopharyngolaryngoscpe with monitor 1

29. IndirectLaryngoscopy mirrors 1

30. Posterior rhinoscopy mirrors 1

31. Dressing trolley with drum with gauze pad 1 set

Total score

Maximum Score 13 18 13 14 15 12 18

Total percentage= Total Score/ Maximum Score x 100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard 2.1.6.1







32

Annex 2.1c Basic Equipment and Instrument for Dental OPD

S.No. Instruments and Equipment for Dental OPD

Required numbers Score

Diagnostic

1. Mouth mirror 10

2. Explorer 10

3. St. Probe 5

4. Tweezers 10

5. Periodontal probe 2

6. Kidney tray small and large 5

7. Plastic tray 10

Extraction forceps

8. Upper premolar 1

9. Upper molar (right) 2

10. Upper molar (left) 1

11. Upper third molar 1

12. Lower cowhorn forceps 3

13. Lower third molar 1

14. Lower root forceps 1

Elevators

15. Compland elevators (small and large) 10

16. Cryers 1 set

17. Pointed elevator 2

18. Apexoelevator 2

Surgical

19. Bp handle 2

20. Needle holder 3

21. Artery forceps 2

22. Toothed forceps 2

23. Scissors (suture cutting) 1

24. 21 no wire 2 packets

25. Wire cutter 1

33

Restorative

26. Airotor handpiece 2

Burs

27. Round burs (smalland large) 5

28. Straight bur 2

29. Inverted cone bur 2

30. Composite finishing bur 1

31. Cement spatula 1

32. Plastic spatula 1

33. Glass slab 1

34. Mixing paper pad 1

35. Cement carrier 5

36. Condenser (round) 5

37. Ball burnisher 2

38. Spoon excavators 5

39. Toffle wire matrix retainer 1

40. Matrix band (steel) 2 packets

41. Matrix band (plastic) 1 packets

42. Wedge 1 packets

43. Dycal tip 2

Dental materials

44. Gic (restorative) 1 set

45. Miracle mix 1 set

46. Composite filling set

47. Etchant 1

48. Bonding agent 1

49. Composite = shades a1 a2a3b1b2 1 each

50. Bonding agent applicator 1 packet

51. Dycal 1 set

52. Cavit(temporary restorative) 1

53. Zinc phosphate (restorative) 1 set

54. Vaseline 1

34

Scaling

55. Suction tips 2 packets

56. Curette (universal curette) 3

Pedo forceps

57. Upper anterior 2

58. Upper root 1

59. Upper molar 2

60. Lower anterior 2

61. Lower molar 2

Additional instruments/supplies

62. Local anesthesia (2% lidocane with adrenaline) 1 box

63. Syringe 1ml 2ml 3ml 1 packet each

64. Gauge 1 packet

65. Cotton roll 1 packet

66. Normal sline 1 bottle

67. Betadine 1 bottle

68. Micromotor (slow speed round bur) 1(2)

69. H2o2 1 bottle

70. Dental floss 1 packet

71. Surgical gloves As per need

72. Loose gloves As per need

Total score

Percentage= Total score/ 72 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Score 2.1.6.5.1

35


Special Clinics 2.2Immunization and Growth Monitoring Clinic

2.2.1

Components Service Standards Obtained Score

Maximum Score

2.2.1.1 Time for patients 2.2.1.1 Immunization and growth monitoring service

is available from 10 AM to 3 PM. 1

2.2.1.2 Staffing 2.2.1.2Adequate numbers of healthcare workers are available (at least 2 mid-level health workers are assigned)

1

2.2.1.3 Maintaining patient privacy

2.2.1.3

Appropriate techniques have been used to ensure the patient privacy (separate rooms, curtains hung, maintaining queuing of patients).

1

2.2.1.4 Patient counseling

2.2.1.4.1Counseling is provided to caretaker about the type of vaccine, its schedule, nutritional status of child.

1

2.2.1.4.2Appropriate IEC/BCC materials on vaccine, schedule and child growth and nutrition are available in clinic

1

2.2.1.5 Instrument, equipment and supplies available

2.2.1.5

Immunization and growth monitoring instrument, equipment and supplies are available (See Annex 2.2.1a Immunization and growth monitoring At the end of this standard)

3

2.2.1.6 Physical facilities

2.2.1.6.1

Adequate rooms and space for health worker and patients are available with at least one working table, chair for health worker and two patients’ chair

1

2.2.1.6.2 Light and ventilation are adequately maintained. 1

2.2.1.7 Recording and reporting

2.2.1.7.1 Patient’s card (Health card, growth chart) and register available and services recorded 1

2.2.1.7.2An adverse event following immunization, complication, severe under-nutrition and referral to other sites recorded and reported

1

2.2.1.8 Infection prevention

2.2.1.8.1 Masks and gloves are available and used 1

2.2.1.8.2There are well labelled colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1

2.2.1.8.3 Hand-washing facility with running water and soap is available for practitioners. 1

2.2.1.8.4 Needle cutter is used. 1

2.2.1.8.5 Chlorine solution is available and utilized. 1

Standard 2.2.1Total Score 17

Total Percentage (Total Score/ 17 x100)

36

Annex 2.2.1a Instruments, equipment and Supplies for Immunization and Growth Monitoring

SN Name Required Quantity Score

1 Weighing scale (Infantometer and Secca Scale) At least one each

2 Stadiometer At least one

3 MUAC tape 2

4 Cold chain box set At least one set

5 Immunization as per national protocol At least two vial/ampule each

6 Different size syringe for immunization (1,2,3,5,10 ml) At least 10 each

7 Cotton in swab container As per needed

8 Container for clean water As per needed

Total score

Percentage = Total score/ 8 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


37

Area Code Verification

Special Clinics 2.2Family planning Clinic 2.2.2


Maximum Score

2.2.2.1 Time for patients 2.2.2.1 Family planning service is available from 10

AM to 3 PM. 1

2.2.2.2 Space 2.2.2.2 A separate area dedicated for FP counseling and services 1

2.2.2.3 Staffing 2.2.2.3Adequate numbers of healthcare workers are available (at least 2 mid-level health workers are assigned)

1


2.2.2.4


1


2.2.2.5.1 Counseling is provided to users for family planning methods 1

2.2.2.5.2Appropriate IEC/BCC materials on family planning including DMT tool used for counseling

1

2.2.2.6 Supplies available 2.2.2.6

Supplies for Family Planning Services available (See Annex 2.2.2a Supplies for FP services At the end of this standard)

3

2.2.2.7 Equipment and supplies available

2.2.2.7 Functional BP set, stethoscope, thermometer, and weighing scale available 1


2.2.2.8.1

Adequate rooms and space for health worker and patients are available with at least one working table, chair for health worker and two patients’ chair and one examination bed

1



2.2.2.9.1 Patient’s health card and register available and services recorded 1

2.2.2.9.2FP related complication, defaulter and contraceptive failure are recorded and reported

1




1




Standard 2.2.2Total Obtained Score 19


38

Annex 2.2.2a Supplies for Family Planning


1. Condoms As per needed

2. Combined oral contraceptive pills As per needed

3. IUD As per needed

4. IUD Insertion and removal Set At least 2

5. Implants As per needed

6. Implants insertion and removal set At least 2

7. Injection Depo provera As per needed

8. Emergency contraceptive pills As per need

9. Sterile surgical gloves (different sizes)

2-3 each of different size

Total score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3



ATT, ART clinic 2.2.3


Maximum Score

2.2.3.1 Time for patients 2.2.3.1 Clinic is open from 10 AM to 3 PM. 1

2.2.3.2 Staffing 2.2.3.2Adequate numbers of healthcare workers are available in OPD (at least 2 mid-level health workers are assigned)

1


2.2.3.3


1

39


2.2.3.4.1Counseling is provided to patients about the type of treatment being given and its consequences.

1

2.2.3.4.2Appropriate IEC/BCC materials on TB, HIV/AIDS (posters, leaflets) are available in the OPD waiting area.

1

2.2.3.5 Medicine available 2.2.3.5

Medicines for TB, HIV/AIDS as per government treatment protocol available in OPD

1

2.2.3.6 Equipment and supplies available

2.2.3.6 OPD has functional BP set, stethoscope, thermometer and weighing scale 1


2.2.3.7.1

Adequate rooms and space for health worker and patients are available with at least one working table, chair for health worker and two patients’ chair

1


2.2.3.8 Facilities for patients

2.2.3.8.1 Safe drinking water with mug or glass is available for taking medicine 1

2.2.3.8.2 Hand-washing facilities are available for patients. 1


2.2.3.9.1 Patient’s card (TB, ART) and register available and services recorded 1

2.2.3.9.2 Drug resistance, complication and referral to other sites recorded and reported 1




1


2.2.3.10.4 Needle cutter is used 12.2.3.10.5 Chlorine solution is available and utilized. 1




Special Clinics 2.2Safe Abortion Services 2.2.4


Maximum Score

2.2.4.1 Time for patients 2.2.4.1 Safe abortion services is available from 10

AM to 3 PM. 1

2.2.4.2 Space 2.2.4.2

A separate area dedicated for Safe Abortion counseling and services, area is washable and has separate instrument processing space for decontamination

1

2.2.4.3 Staffing

2.2.4.3.1At least one medical officer or gynecologist trained and certified in first trimester SAS is available

1

2.2.4.3.1For surgical abortion, at least one medical officer or gynecologist or MDGP trained and certified in second trimester SAS is available

40


2.2.4.4


1


2.2.4.5.1

Counseling is provided to users on Safe Abortion Services, complication and family planning post abortion along with clear discharge instructions

1

2.2.4.5.2

Appropriate IEC/BCC materials on safe abortion services and post abortion family planning services –Medical Abortion Chart, CAC counseling flip chart, second trimester counseling flipchart, DMT Tools used for counseling

1

2.2.4.6 WHO Safe Surgery Checklist available

2.2.4.6WHO safe surgery checklist is available and used for safe abortion services including written informed consent

2.2.4.7 Instruments, equipments and Supplies available

2.2.4.7.1

Instruments, equipments and supplies for Safe Abortion Services available (See Annex 2.2.2a Instruments, equipments and supplies for Safe Abortion services At the end of this standard)

3

2.2.4.7.2 Functional BP set, stethoscope, thermometer, and weighing scale available 1

2.2.4.8Physical facilities

2.2.4.8.1

Adequate rooms and space for health worker and patients are available with at least one working table, chair for health worker and two patients’ chair, one examination bed, one procedure table and one foot step

1


2.2.4.9 Recording, reporting and histological examination

2.2.4.9.1Patient’s health card and register available and services recorded along with complications if any

1

2.2.4.9.2 Product of conception is sent for histopathlogical examination and reports followed up

1


2.2.4.10.1 Utility Gloves, Gumboot, Mask, Plastic Apron, Caps are available and used 1


1






41

Annex 2.2.4a Instruments, equipments and supplies for Safe Abortion services


1. Shelf for storage At least 1

2. Reliable Light source (goose neck light) At least 1

3. Oxygen concentrater/ Oxygen filled cylinder with flow meter and mask At least 1 Set

4. Light view box with glass/ plastic container and sieve for POC check At least 1 each

5. Intubation set adult 1 set

6. IV stand At least 1

7. Surgical drum (2) As per needed

8. Sterilized Chettle forceps with jar At least 2

9. Bivalve Speculum (3 sized- small, medium and large) At least 3 each

10. Stainless steel container with cover for storing instruments At least 2

11. Cheatle’s forceps with jar At least 2

12. Instrument trolley At least 2

13. Abdominal drapes As per need

14. MVA aspirator At least 2

15. MVA cannula sizes 4-12 At least 2 each

16. MVA cannula number (14 & 16) At least 2 each

17. MVA set At least 2 Set

18. D&E set At least 2 Set

19. Suture set with Long needle holder At least 2

20. Combi-pack (Mifepristone and Misoprostol)

21. Misoprostol only to treat incomplete abortion

22. Antibiotics (Injection Metronidazole 500mg/100ml, Tab Azithromycin 500mg) As per need

23. Uterotonics (Injection Oxytocin, Tablet Misoprotol, Injection ergometrine) As per need

24. Injection Xylocaine 1% /2% without adrenaline 2 vail each

25. Injection Atropine 10 ampules

42

26. Injection Adrenaline 10 ampules

27. Injection Hydrocortisone At least 3 vail

28. Injection Dexamethasone At least 3 vail

29. Distilled Water (100ml) At least 2 bottles

30. Gloves (disposable) for P/V examination At least 2 box

31. Surgical gloves different size At least 2 each

32. Betadine Solution At least 1 bottle

33. Disposable syringes 2 ml, 5 ml, 10 ml, 20 ml At least 5 each

34. ET tubes of different size At least 2 of each size

35. IV fluids (Normal Saline 0.9%, Ringers; Lactate, Dextrose 5% Normal Saline 0.9%) At least 5 each

36. IV Infusion set At least 5

37. IV canula (18 Gz, 20Gz) At least 2 each

38. Foley’s catheter and Urobag, At least 2 set

39. Sutures of different size At least 5 each

40. Soft brush for cleaning equipments At least 2

41. Bucket or Basin 2-3 each of different size

42. IP flex available for processing MVA aspirator and cannula One

Total score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


43

Area CodeVerification Emergency

Service 2.3.1

Components Service Standards Obtained score

Maximum score

2.3.1 Time for patients 2.3.1 Emergency room/ward is open 24 hours 1

2.3.2 Staffing (per shift in ER)

2.3.2.1.1 For 5-10 ER beds (Doctor: Nurse: Paramedics: Office Assistant = 1:1:1:1) 1

2.3.2.1.2For every increased 5 ER beds, proportionate additional health workers is done (Doctor: Nurse: Paramedics: Office Assistant = 1:1:1:1)

1

2.3.2.2 There should be 1:1 nurse patient ratio in red area, 1:3 in yellow area and 1:6 in green area. 1

2.3.2.3 The doctor, nurse and paramedics are trained in PTC, ETM, BLS and ACLS2 training 1


2.3.3.110% of the total hospital beds are allocated for ER of which 1% for red, 2% for yellow, 3% for green and 1 % for black color coded

1

2.3.3.2Adequate furniture and supplies (See Annex 2.3a Furniture and General Supplies for ER At the end of this standard)

3

2.3.3.3 Light and ventilation are adequately maintained. 1

2.3.3.4Designated area for nursing station centrally placed in ER and all beds visible from nursing station

1

2.3.3.5Space allocated for duty room and changing room separate for male and female staffs with facilities of tea room

1

2.3.3.6 Separate toilets for staffs at least one each-male, female and universal 1

2.3.3.7 Separate land line/ mobile phone for emergency 1

2.3.4 Instruments/ equipment

2.3.4

Instruments and equipment to carry out the ER works are available and functioning (See Annex 2.3b ER Instruments and Equipment At the end of this standard)

3

2.3.5 Medicines and supplies

2.3.5.1

Medicines and supplies to carry out the ER works are available (See Annex 2.3c Medicines and Supplies for ER At the end of this standard)

3

2.3.5.2 Emergency stock of medicines and supplies for mass casualty management 1

2.3.6 Triage

2.3.6.1 Hospital maintains a triage system in the ER with 24 hours triage service 1

2.3.6.2Triage category board and information to the public (Red, Yellow, Green Board) (descriptive flex)

1

2 PTC- Primary Trauma Care, ETM- Emergency Trauma Management, BLS- Basic Life Support, ACLS- Advanced Cardiac Life Support

44

2.3.7 Emergency protocol in place

2.3.7.1

In red area one of the bed is Resuscitation bed with availability of emergency crash trolley with emergency lifesaving drugs, cardiac monitor, non-invasive ventilator, oxygen concentrator

1

2.3.7.2

Development of 001 or Blue code call system whenever any patient visited in Emergency collapses and need immediate and urgent emergency care

1

2.3.7.3Emergency disposition of the patient either in observation ward or definite care ward or referral or discharge within 3-6 hours

1

2.3.7.4

Critical patient transfer from emergency to OT or Inter-hospital transfer is accompanied at least by paramedics or Nurse for handover of patient

1

2.3.8 Maintaining patient privacy 2.3.8

Appropriate methods have been used to ensure patient privacy (separate rooms, curtains hung)

1

2.3.9 Security 2.3.9 The hospital has maintained security system for ER for 24 hours with CCTV coverage 1

2.3.10 Mass casualty/ disaster preparedness

2.3.10.1The hospital has mass casualty management protocol, and all staffs are updated with well labelled direction, prepositioning clipboards

1

2.3.10.2 Disaster area identified with adequate furniture to carry out Triage in case of disaster 1

2.3.10.3 Hospital carried out at least one mock preparedness once a year 1

2.3.10.4

There must be disaster store in ER with required medicines, supplies and equipment (See Annex 2.3d List of medicine, supplies and equipment for Disaster Store At the end of this standard)

3

2.3.11 Duty rosters 2.3.11 Duty rosters of the ER are developed regularly

and available in appropriate location 1

2.3.12 Maintaining inventory

2.3.12 Separate inventories for emergency lifesaving drugs/equipment and narcotics are maintained 1

2.3.13 Securing narcotic drugs 2.3.13 Narcotic drugs are kept separately and

securely with mandatory recording system 1


2.3.14.1 Safe drinking water is available 24 hours 1

2.3.14.2 Hand-washing facility with running water and liquid soap 1

2.3.14.3

There are at least 3 toilets with hand-washing facilities (1 for males, 1 for females, and 1 universal) for every 10 ER beds and for additional beds increase proportionately for male and female

1

45

2.3.15 Decontamination area

2.3.15 Decontamination area specified and practiced 1


2.3.16.1 Staff wear mask and gloves at work 1

2.3.16.2There are clearly labelled colored bins for waste segregation and disposal as per HCWM Guideline 2014 (MoHP)

1

2.3.16.3 Needle cutter is used 1

2.3.16.4 Chlorine solution is available and utilized for decontamination 1



Annex 2.3a Furniture and General Supplies for ER

S.No. Furniture and General Supplies Required Quantity Score

1. Wheel chair 2 for every 5 ER beds

2. Trolley 1 for every 5 ER beds

3. Stretcher 1 for every 5 ER beds

4. Information board 1

5. Foot Step 2 for every 5 ER beds

6. Working Table/Station with 2 chairs 1

7. Stool (for visitor) each bed 1

8. Medicine Rack 1

9. Supplies Rack 1

10. Waste Bins (color coded and labelled as per HCWM guideline)

1 set for every 5 ER beds

11. Poisoning Chart 1

12. Telephone set/Mobile 1

13. Reference Books with cupboard 1

14. Cup Board for narcotics 1

15. Screen As per need

16. Cart/Trolley with medicines for emergency procedures 1

17. IV stand At least one per bed

18. Bed Pan 2 for every 5 bed

19. Urinal 2 for every 5 bed

Total Score


46


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.3b ER Equipment and Instrument

SN Equipment /Instruments Required No. Score

1. ECG machine (12 Leads) 1

2. Defibrillator 1

3. Foot / Electric Suction Machine 2

4. Portable ventilator/ Non-invasive ventilator 1

5. Positive Airway Pressure machine with accessories 1

6. Nebulizer set 1

7. Cardiac monitors with non-invasive BP cuffs

1 in every bed in red area; 1 for every 2 beds in yellow area

8. BP set and Stethoscope (each treatment room) 2

9. Pulse oximeter 1

10. Glucometer with strips 1

11. Duck Speculum 2

12. Protoscope 2

13. Otoscope set 1

14. Nasal Speculum 1

15. Laryngoscope with batteries and blades 2

16. ET tubes of different sizes At least 2 each

17. Torch Light 2

47

18. Geudel Airway 2

19. Ambu Bag (Adult and Pediatric) 2

20. Bougie 2

21. Endotracheal tube of different sizes 6

22. Different size mask 6

23. Laryngeal mask airway (Adult and Peadiatric) 1 each

24. Oxygen tubes and masks 10 each

25. Suture Set 4

26. Catheterization set 2

27. Dressing set 2

28. Water sealed drainage set 1

29. N/G tube Aspiration set 1

30. Ear Irrigation Set 1

31. Cervical collar 4

32. Spinal backboard 1

33. Splints 3

34. Arm Slings 3

35. Portable Light 2

Total Score

Total Percentage = Total Score/35X 100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


48

Annex 2.3c Medicines and supplies for ER (required number proportionate to ER beds 1:2)

SN Name Score

1. Atropine Injection

2. Adrenaline Injection

3. Xylocaine 1% and 2% Injections with Adrenaline

4. Xylocaine 1% and 2 % Injections without Adrenaline

5. Xylocaine Gel

6. Diclofenac Injection

7. Hyoscine Butylbromide Injection

8. Diazepam injection

9. Morphine Injection / Pethidine Injection

10. Hydrocortisone Injection

11. Antihistamine Injection

12. Dexamethasone Injection

13. Ranitidine/Omeperazole Injection

14. Frusemide Injection

15. Dopamine injection

16. Noradrenaline injection

17. Digoxin injection

18. Verapamil injection

19. Amidarone injection

20. Glyceryl trinitrate injection/ tab

21. Labetolol injection

22. Magnesium Sulphate injection (loading dose)

23. Sodium bicarbonate injection

24. Calcium Gluconate injection

25. Ceftriaxone Injection

26. Metronidazole Injection

27. Charcoal Power

28. Normal Saline Injection

49

29. Ringers’ Lactate Injection

30. Dextrose 5% Normal Saline Injection

31. Dextrose 5% Injection

32. Dextrose 25%/50% Injection (ampoule )

33. IV Infusion set (Adult/Pediatric)

34. IV Canula (16, 18, 20, 22, 24, 26 Gz)

35. Foley’s Catheter (different French)

36. Disposable syringes (1 ml, 3 ml, 5 ml, 10 ml, 20 ml, 50 ml)

37. Disposable Gloves (Size- 6, 6.5, 7, 7.5)

38. Distilled Water

39. Sodium chloride-15%w/v and Glycerin-15% w/v (for enema)

Total Score

Total Percentage = Total Score/39 X100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.3d List of equipment, instrument, medicine and supplies for Disaster Store

S.No. Equipment and Instruments Required Number Score

1. Stretcher/ trolley 5

2. Spinal boards 5

3. Wheel chairs 5

4. Medicine trolley 2

5. Portable suction machine 2

6. Nebulizer machine 2

50

7. Fluid warmer 2

8. BP instrument 10

9. Stethoscope 10

10. Saturation probe 5

11. Thermometer 5

12. Suture sets 5

13. Dressing sets 5

MEDICINES

14. Tetanus Toxoid Injection 50

15. Diclofenac Paracetamol Injection 50

16. Tramadol Injection 50

17. Ondensterone Injection 50

18. Cefazoline Injection 20

19. Metronidazole Injection 20

20. Ketorolac Injection 20

21. Transemic Acetate Injection 20

22. Atropine Injection 50

23. Adrenaline Injection 50

24. Midazolam Injection 20

25. Xylocaine 2% Injection 20

26. Vitamin B-complex Injection 20

27. Succinylcholine Injection 20

28. Normal Saline /Ringers’ Lactate/ Dextrose 5% Normal Saline Injection 20 each

29. Hemaecel Injection 5

Intubation articles

30. Ambu bag (adult,paed.) 10

31. Resuscitation masks (adult, pediatric, newborn) 10 each

32. ET tubes different size 5 each

33. Airways 5

34. Laryngoscope 5

35. ECG Leads 30

51

SUPPLIES

36. Triage tags 100

37. Extra I/V stand 20

38. Portable oxygen cylinder 5

39. Plastic aprons 10

40. Gowns 10

41. Extra Mattress 50

42. Blankets 50

43. Screens 3

44. Scissors 5

45. Splints 15

46. Cervical collar(hard/soft) 20

47. Arm slings 20

48. Pelvic binder 5

49. Bandages 50

50. Crepe bandage 20

51. Elastoplast 20

52. Leuckoplast 20

53. Nebulizer kit set 2

54. Oxygen masks 10

55. Pressure Monitoring (PMO) line (for infusion) 10

56. Chest tube set (No.28,32) 10

57. Drainage bag 20

58. Foleys catheter/ urobag 20 each

59. Surgical gloves Different Size 30 of each size

60. Examination gloves 2 boxes

61. Utility gloves 10

62. Betadine /spirit 10

63. IVCannulas of all size, IV set and Buret Set 20 each

64. Syringes of different size (3ml,5ml, and 10ml) / (20ml, 50ml)

50 each/ 20 each

65. Suction tubes different size 5 each

52

66. Yanker suction 1

67. Sterile gauze, cotton, dressing pads. 1 medium size steel drum each

68. Hand Sanitizer 20

69. Torch lights 5

70. Note book 10

71. Ball pens 10

Total score

Total percentage = Total Score/ 71 x100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Area Code VerificationEmergency

Minor OT 2.4


Maximum Score

2.4.1 Working space 2.4.1 A separate space dedicated for emergency minor

operative procedures 1

2.4.2 Furniture & general supplies

2.4.2

Adequate furniture and general supplies are available (See Annex 2.4a Furniture and General Supplies for ER Minor OT At the end of this standard).

3

2.4.3 Services available 2.4.3

Minimum dressing services and routine procedures are available (See Annex 2.4b List of Minimum Services from ER Minor OT At the end of this standard).

3

2.4.4 Staffing 2.4.4 Duty roster prepared to assign staffs for emergency minor OT 1

2.4.5 Disposable supplies

2.4.5

Medicines and supplies needed for surgical procedures available (See Annex 2.4c Medicine and Supplies for Minor OT At the end of this standard).

3

53

2.4.6Sterile supplies

2.4.6.1Sterile supply for Minor OT are available (See Annex 2.4d Sterile Supplies for Minor OT At the end of this standard).

3

2.4.6.2 Separate containers for sterile gauze and cotton balls are available. 1

2.4.7 Anesthesia services available

2.4.7.1

Minor OT has equipment, instrument and supplies for anesthesia services (See Annex 2.4e Equipment, Instrument and Supplies for Anesthesia for Minor OT At the end of this standard).

3

2.4.7.2

Minor OT has medicines and supplies for anesthesia services (See Annex 2.4f Medicine and Supplies for Anesthesia for Minor OT At the end of this standard).

3

2.4.8 Infection prevention and waste disposal

2.4.8.1 Mask, gloves, plastic apron, boots and goggles are available and used whenever required. 1

2.4.8.2 At least three color coded waste bins as per HCWM guideline are available and used 1

2.4.8.3 Supplies trolley with needle cutter is available and used 1

2.4.8.4 Hand-washing facility with running water and soap 1


2.4.9 Documentation 2.4.9 Proper records of all procedures are kept and

reported. 1



Annex 2.4a Furniture, Equipment, Instruments and Supplies for Minor OT

SN General Equipment and Instruments for OT Standard Quantity Score

1. Wheel chair foldable, adult size 1

2. Stretcher 1

3. Patient trolley 1

4. Cupboards and cabinets for store 1

5. Working desk for anesthesia, nursing station, gowning 1 each

6. OT Table- universal type/ with wedge to position patient At least 1

7. Examining table 1

8. Mayo Stand with tray 2

9. Operation theatre lights 1

10. Ultra violet light source 1

11. Electronic suction machine/ Foot-operated suction machine 1/1

12. Refrigerator / cold box 1

54

13. Anesthesia machine with cardiac monitor 1

14. Cautery/Diathermy machine 1

15. Oxygen concentrator/ Oxygen Cylinder 1

16. Baby warmer 1

17. Baby weight machine 1

18. Anesthesia trolley 2

19. Instrument trolley 2

20. BP instrument with stethoscope 1

21. Thermometer 1

22. Steel Drum for gloves 1

23. Steel Drum for Cotton 1

24. Tourniquet, latex rubber, 75 cm 2

25. Kidney tray (600cc) 2

26. Covered instrument trays 4

27. Mackintosh sheet 1

28. Lead gown 2 sets

29. Bowl stand 2

30. Cheatle forceps in jar 2

31. Drapes for abdominal site (laparotomy sheet, table cover, hook towel, mayo cover, plastic sheet, tetra)

As per need

32. Drapes for perineal region(Laparotomy sheet, table cover, hook towel, mayo cover, plastic sheet, tetra, leggings)

As per need

33. Packing towel double wrapper As per need

34. Sterile gloves (6,6.5,7,7.5,8) 5/5/5/5/5/5

35. Towels/ eye hole As per need

36. Masks and caps As per need

37. Torch light and batteries 1 set

38. Foot steps 2

39. Wall clock 1

40. Waste bucket for scrub nurse 1

41. IV stand 2

42. Leak proof sharp container 1

43. Generator back up for OT 1

44. Gas/ Kerosene stove- 4 burners 1

45. Color coded waste bins (based on HCWM guideline 2014 (MoHP)) 1 set

Total Score

Total percentage= Total/ 45 x 100

55

Each row gets a score of 1 if the mentioned test is available otherwise 0.

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.4b List of Minimum Services from ER Minor OT

S.No. List of Minimum Services from ER Minor OT Score

Minor

1. Incision & Drainage under Local Anesthesia

2. Excision of cysts, ganglion, lump, lymhnode, lipoma, skin papilloma, corn under LA

3. Excision of ingrowing toe nail under digital block

4. Breast Abscess aspiration

5. Wound debridement

6. Skin suturing < 5cm size

7. Foreign Body removal under LA

8. Repair split ear

9. True cut biopsy

10. Chest tube insertion under LA

11. Circumcision Under LA

12. Eversion of sac for hydrocele (EVS)

13. Haemorrhoid banding

Manual Vacuum Aspiration or Removal of Product of conception

Intermediate

14. Herniotomy under IVA

15. Mesh Repair / Darn Repair (under LA/SA)

16. Amputation

17. Large wound dressing / debridement under IVA/SA

56

18. Chest tube insertion under IVA

19. Circumcision under IVA

20. Incision & Drainage under IVA eg. Breast abscess, perineal abscess

21. Haemorrhoidectomy

Total score

Total Percentage= Total score/22 x 100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.4c Medicine and Supplies for Minor OT

SN Emergency Drugs (including neonates) for OT Standard Quantity for 1 patient Score

1. Midazolam Injection 5 vials

2. Hydrocortisone Powder for Injection 100ml 2 vial

3. Frusemide Injection 2 ampules

4. Dopamine Injection 5 vials

5. Transemic Acetate Injection 2 ampules

6. Hydralizine Injection 5 vials

7. Calcium Gluconate Injection 10ml X 2 ampules

8. Magnesium sulphate Injection 0.5 gms X 28

9. Oxytocin Injection 10 Ampules

10. Dextrose (25%) / (50%) Injection 2 ampules

11. Naloxone Injection 1 ampule

12. Aminophyline Injection 2 ampules

13. Chloropheniramine Injection 2 ampules

14. Mephentine Injection 1 vial

57

15. IV Fluids- Ringers Lactate / Normal Saline/ Dextrose 5% Normal Saline/ Dextrose 5% 6 bottles each

16. IV infusion Set 4

17. IV Canula 22G/20G/18G 4 each

Total Score

Total Percentage = Total Score/17 X 100Each row gets a score of 1 if all the required number is available otherwise 0

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.4d Sterile Supplies for Minor OT

S.No. Items Required number Score

1. Catheter set At least 5

2. Suture set At least 5

3. Manual Vacuum Aspiration Set with Canuula and Aspirator of different size At least 2

4. Dressing set of different size (small, medium, large)

At least 2 each

5. Incision and drainage set At least 5

6. Laparotomy set At least 2

Total Score

Total Percentage= Total Score/6x100

Each row gets a score of 1 if all the required number is available otherwise 0

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


58

Annex 2.4e Equipment, Instrument and Supplies for Anesthesia for Minor OT

S.No. List of equipment, instruments and supplies for anesthesia Required Number Score

1. Supply of oxygen (e.g., oxygen concentrator, cylinders or pipeline) with regulator and flow meter

At least 2 oxygen concentrator

2. Oropharyngeal airways (Size 000, 00, 0, 1, 2, 3, 4) At least 2 each

3. Anesthesia face masks (Size 0, 1, 2, 3, 4) At least 2 each

4.

Laryngoscope, Mc Coy's curved blade and Miller's straight blade (small, medium and large sizes for both adult and pediatric patients)

At least two

5. Endotracheal tubes, cuffed, uncuffed, different sizes (Sizes 2.5 - 8.0 ID)

At least two of each size

6. Intubation aids (Magillsforcep of small and large size, bougie, stylets of small and large size)

As per need

7. Suction device and suction catheters of different sizes (Size 8 -16 Fr) As per need

8. Adult and pediatric self-inflating bags (Size 2L, 1L, 0.5L) As per need

9.

Equipment for intravenous infusions and injection of medications for adult and pediatric patients (IV stand, IV canula, fixing tapes, infusion sets, blood transfusion sets, burette sets, syringes, three-way stop cocks)

As per need

10. Examination (non-sterile) gloves As per need

11. Sterile gloves As per need

12. Pulse oximeter At least 2

13. Access to a defibrillator At least 1

14. Stethoscope At least 2

15. Sphygmomanometer with appropriate sized cuffs for adult and pediatric patients As per need

16. Non-invasive blood pressure monitor with appropriate sized cuffs for adult and pediatric patients

As per need

17. Electrocardiogram - three leads As per need

18. Temperature monitor (intermittent) As per need

Total Score

Total percentage = Total score/ 18 x 100

59


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.4f Medicines and Supplies for Anesthesia for Minor OT

S.No. List of Medicines Required Number Score

Preoperative medications

1. Ranitidine Injection 5

2. Metoclopramide Injection 5

3. Aluminium hydroxide or magnesium trisilicate suspension 5


5. Diazepam Tablet 5

Intraoperative medications

6. Ketamine Injection 3


8. Opioid analgesics injections ( Morphine, Pethidine, Fentanyl) 2 each

9. Lignocaine 2% Injection for IV infusion 2

10. Lignocaine Inj 1%, 2% with or without Adrenaline 1:200000 2

11. Thiopental Powder 500mg As per need

12. Propofol Injection As per need

13. Appropriate inhalational anesthetic (Halothane, Isoflurane, Sevoflurane) As per need

14. Succinylcholine Injection As per need

15. Appropriate non-depolarizing muscle relaxant (Pancuronium, Vecuronium, Rocuronium, Atracurium Injections)

As per need

16. Neostigmine Injection As per need

17. Atropine Injection / Glycopyrolate Injection 10/10

18. Bupivacaine Heavy 0.5% 2

60

Intravenous fluids

19. Water for injection As per need

20. Normal saline / Ringer’s lactate As per need

21. 5% Dextrose / Dextrose normal saline As per need

22. 1/5Dextrose 1/3Normal saline As per need

23. Mannitol Inj 20% As per need

24. Haemaccel Injection / Gelafusine Injection / Voluven Injection As per need

Resuscitative medications

25. Dextrose 25%/ 50% Injection 5 each

26. Mephenteramine or Ephedrine Injection 5

27. Dopamine Injection 5

28. Noradrenaline Injection 5

29. Amiodarone Injection 5

30. Hydrocortisone Injection 5

31. Dexomethasone Injection 5

32. Chlorpheniramine Injection 5

33. Calcium gluconate Injection 5

34. Beta-blockers (Metoprolol, Labetolol, Esmolol) Injection As per need

35. Naloxone Injection 5

Post-operative medications

36. Morphine Injection As per need

37. Pethidine Injection As per need

38. Tramadol Injection As per need

39. Pentazocine Injection As per need

40. Paracetamol Injection 1gm, Suppository 125mg As per need

41. Diclofenac Injection As per need

42. Ketorolac Injection As per need

43. Promethazine Injection As per need

44. Ondansetron Injection As per need

45. Gabapentin Injection As per need

Other medications

61

46. Magnesium Injection As per need

47. Salbutamol Injection (for inhalation) As per need

48. Ipratropium bromide Injection (for inhalation) As per need

49. Furosemide Injection As per need

50. Glyceryl trinitrate/nitroglycerine Injection As per need

51. Sodium nitroprusside Injection As per need

52. Heparin Injection As per need

53. Aminophylline Injection As per need

Total Score

Total percentage = Total score/ 53x 100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Area Code

VerificationHospital Pharmacy Service

2.5


Maximum Score

2.5.1 Pharmacy department available

2.5.1 Hospital has designated pharmacy department 1

2.5.2 Governance committee for hospital pharmacy services

2.5.2. Governance committee for hospital are formed based on hospital pharmacy-service guideline:

2.5.2.1 Drug and Therapeutic committee (DTC) 1

2.5.2.2 Hospital pharmacy operation committee 1

62

2.5.3 Hospital formulary Heading: Availability of medicines and supplies

2.5.3.1Hospital has hospital formulary based on Nepalese National Formulary (NNF) approved by DTC

1

2.5.3.2Hospital formulary includes all medicines and supplies as per services provided by hospital

1

2.5.3.3Hospital has all ,medicines and supplies available as per approved hospital formulary list

1

2.5.4 Good procurement practice

2.5.4.1 Annual procurement plan for medicines and supplies for pharmacy services is available 1

2.5.4.2 Procurement is done based on public procurement guideline 1

2.5.4.3Product specification for each medicine and related supplies of approved formulary list is available

1

2.5.4.4Technical criteria on quality assurance of procured medicines is included in standard bidding document

1

2.5.4.5Certificate of analysis (CoA) from manufacturer of each batch of procured medicine is available

1

2.5.3.4 Selling price of the drugs does not exceed 20% of the procurement price 1

2.5.4 Pharmacy service hours 2.5.4 The pharmacy is open 24x7 1

2.5.5 Staffing as per hospital pharmacy service guideline 2072

2.5.5.1 Pharmacy department is led by at least one clinical pharmacist

1

2.5.5.2 Pharmacy has at least 3 pharmacist, 6 assistant pharmacist and 2 office assistants 1

2.5.5.3 Duty roster of pharmacy to cover 24 hours service is prepared and visibly placed 1

2.5.7 Display of list of free medicines

2.5.7 The list of free medicines is displayed in a clearly visible place. 1

2.5.8 Availability of medicines for specific programs

2.5.8

All of the required medicines and supplies for specific programs are available in pharmacy (less than 50%= 0; 50-70 =1, 70-85=2 85-100= 3)

3

2.5.9 Inpatient pharmacy services available

2.5.9 Hospital pharmacy directly supplies inpatient medicine and supplies to wards and OT 1

2.5.10 Electronic record keeping 2.5.10 Pharmacy uses computer with software for

inventory management and medicine use 1

2.5.12 Pharmacy stock available 2.5.12

Number of items of hospital formulary stocked in pharmacy(less than 50%= 0; 50-70 =1, 70-85=2 85-100= 3)

3

63

2.5.13 Display and storage of medicines

2.5.13.1

All the medicines and supplies are displayed in clean racks following either alphabetical orders and generic names or grouping as use

1

2.5.13.2Temperature of pharmacy is monitored and recorded and is maintained in range of (25+/-2°C)

1

2.5.13.3 Functional freeze +/-4°C for thermolabile medicine 1

2.5.14 Information to patients

2.5.14.1Pharmacy department has its allocated separate information and counseling unit with reference books or e-books

1

2.5.14.2 Information regarding the medicines is provided to the patients. 1

2.5.14.3

IEC materials (posters, leaflets, national hospital formulary) about the appropriate use for medicines are available in the pharmacy area.

1

2.5.15 Generic prescription 2.5.15 Hospital has pre-printed list of medicines for

generic prescription available 1

2.5.16 Dispensing medicines

2.5.16.1 Medicine is dispensed using electronic billing with barcode system 1

2.5.16.2 Each medicine is given with written instructions on how to take 1

2.5.17 First Expiry First Out (FEFO)

2.5.17 FEFO system is maintained using standard stock book/cards. 1

2.5.18 Pharmacy Inventory 2.5.18

Every month, all medicines and supplies are counted, out- of-date discarded, and tallied with the medical store.

1

2.5.19 Drug utilization review and quantification of data

2.5.19.1Pharmacy department operates pharmacovigilance activities and adverse drug reaction (ADR) Reporting

1

2.5.19.2 Pharmacy department conducts studies on drug utilization and quantification 1

2.5.19.3Antimicrobial stewardship programme , proper antimicrobial utilization review and provide data on antimicrobial use

1

2.5.20 Pharmaceutical waste disposal

2.5.20

Pharmaceutical waste (expired or unused pharmaceutical products, spilled contaminated pharmaceutical products surplus drugs, vaccines or sera, etc) management is done based on HCWM guideline 2014 (MoHP) or returned to the supplier on time

1


Total Percentage (Total Obtained Score/40 x100)

64

Area Code

VerificationInpatient Service3

2.6


Maximum Score

2.6.1 Space for work

2.6.1.1Separate space for nursing station is available in each ward (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.1.2Separate changing room available for male and female staffs (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.1.3Separate store room is available (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.1.4 One ward should not exceed 25 beds for general ward 1

3 Separate Set of Sheets for Assessment of Service Standards including - Checklist and Annexes, should be used for Each Ward Allocated for Inpatient Service and scoring of cumulative standards is done at end of all inpatient wards’ assessment

65

2.6.2 Furniture and supplies available and functioning

2.6.2 Furniture and supplies to carry out the inpatient services are available and functioning

2.6.2.1Medicine Ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.2Surgery Ward(See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.3.1Pediatrics Ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.3.2Separate area dedicated for play room with play materials for different pediatric age groups

1

2.6.2.4

Orthopedics ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.5.1Psychiatry ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.5.2 Separate area dedicated for recreational activities for psychiatry patients 1

2.6.2.5.3

Separate space designated for ECT procedure with treatment bed, ECT machine, emergency trolley with medicines and supplies

1

2.6.2.6

ENT Ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.7

PNC and Gynecology Ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

2.6.2.8

Geriatrics Ward (See Annex 2.6a Furniture and supplies for inpatient wards At the end of this standard)

3

66

2.6.3 Medicine and supplies available

2.6.3 Medicine and supplies to carry out the inpatient services are available in wards

2.6.3.1Medicine Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.2Surgery Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.3Pediatrics Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.4

Orthopedics ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.5Psychiatry ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.6ENT Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.7

PNC and Gynecology Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.3.8Geriatrics Ward (See Annex 2.6b medicine and supplies for inpatient wards At the end of this standard)

3

2.6.4 Nursing station 2.6.4

There is a set of at least one table and two chairs in the nursing station and shelves for storage of charts and inpatient forms and formats (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.5 Nursing staff and support for inpatient service

2.6.5

Adequate numbers of nursing staff are available in ward per shift (nurse patient ratio 1:6 in general ward, 1:4 in pediatric ward, 1:2 in high dependency or intermediate ward or post-operative ward or burn/plastic) and at least one trained office assistant/ward attendant per shift in each ward (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.6 Duty rosters 2.6.6

Duty roster of doctors, nurses, paramedics and support staffs kept visibly in nursing station (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.7 Communication 2.6.7

Telephone facility is available with list of important contact numbers and hospital codes visibly kept (See Checklist 2.6 At the end of this standard for scoring)

3

67

2.6.8 Emergency management of inpatients

2.6.8.1

All staffs in wards are trained for BLS and oriented about emergency code 001 or blue code (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.8.2 At least one emergency trolley with emergency medicine available in ward

2.6.8.2.1Medicine Ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.2Surgery Ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.3Pediatrics Ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.4Orthopedics ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.5.1Psychiatry ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.5.2ECT room (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.6ENT Ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.7

PNC and Gynecology Ward(See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.2.8Geriatric Ward (See Annex 2.6c Emergency Trolley for Inpatient At the end of this standard)

3

2.6.8.3At least one defibrillator in immediate accessible area (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.9 Safe Abortion Service (SAS) available

2.6.9Safe abortion service (SAS) is available as per National SAS Implementation Guideline

1

68

2.6.10 Physical facilities for patient

2.6.10.1

Separate area designated for admission of male and female inpatients in wards (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.10.2

There are adequate separate toilets for male and female patients in each ward (1 for 6 female bed and 1 for 8 male beds) and also adequate wash basins/sinks for the patients. (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.10.3Patient safety in taken care of in all inpatient wards including proper fixation of the furniture and equipment

1

2.6.10.4 Separate waiting area for visitors. 1

2.6.10.5

For psychiatry ward, ensure that there is special arrangements for securing all furniture, equipment and instrument; all doors with no internal laches or locks, all the windows have grills and half doors in toilets and bathrooms for visible head and foot parts from outside

1

2.6.10.6Safe drinking water is available 24 hours for inpatients(See Checklist 2.6 At the end of this standard for scoring)

3

2.6.10.7

Hours/ Time allocated for visitors to meet the inpatients and controlled traffic to prevent cross infection (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.10.8 Separate space is available for patients’ visitors (KuruwaGhar). 1

2.6.11 Communication and counseling

2.6.11.1

Basic information regarding admitted patients is displayed in a separate board (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.11.2

Separate space with privacy dedicated for regular counselling is done for patient and patient party on condition and disease of patient (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.12 IEC/BCC Materials 2.6.12

Appropriate IEC/BCC materials (posters, leaflets etc.) are available in the inpatient ward with focus on infection prevention (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.13 Recording and reporting 2.6.13

Admission and discharge registers are available and are being filled completely (HMIS 8.1 and 8.2) (See Checklist 2.6 At the end of this standard for scoring)

3

69


2.6.14.1PPE4 are available and used whenever required (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.14.2

Each ward has hand sanitizer in visible place for health workers to use before and after touching patients (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.14.3

There are well labelled color-coded bins for waste segregation and disposal as per HCWM5 guideline 2014 (MoHP) (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.14.4

Hand-washing facility with running water and liquid soap is available and being practiced (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.14.5 Needle cutter is used (See Checklist 2.6 At the end of this standard for scoring) 3

2.6.14.6Chlorine solution is available and utilized for decontamination (See Checklist 2.6 At the end of this standard for scoring)

3

2.6.14.7 Separate isolation room for any communicable disease patients 1


Total Percentage (Total Obtained Score/ 154x100)

Checklist 2.6 Inpatient Services(1= Medicine Ward 2= Surgery ward 3= Pediatrics Ward 4= Orthopedics ward 5=Psychiatry Ward 6= ENT ward 7= PNC and Gynecology Ward, 8= Geriatrics Ward)

Code Service Standards 1 2 3 4 5 6 7 8 Total

Score Percentage Scoring Direction to Use

2.6.1.1

Separate space for nursing station is available in each ward


2.6.1.2

Separate changing room available for male and female staffs


2.6.1.3 Separate store room is available


4 PPE = Personal Protective Equipment

5 HCWM = Health Care Waste Management

70

2.6.4

There is a set of at least one table and two chairs in the nursing station and shelves for storage of charts and inpatient forms and formats


2.6.5

Adequate numbers of nursing staff are available in ward per shift (nurse patient ratio 1:6 in general ward, 1:4 in pediatric ward, 1:2 in high dependency or intermediate ward or post operative or burn/plastic ward) and at least one trained office assistant/ward attendant per shift in each ward


2.6.6

Duty roster of doctors, nurses, paramedics and support staffs kept visibly in nursing station


2.6.7

Telephone facility is available with list of important contact numbers and hospital codes visibly kept


2.6.8.1

All staffs in wards are trained for BLCS and oriented about emergency code 001 or blue code


2.6.8.3

At least one defibrillator in immediate accessible area


2.6.10.1

Separate area designated for admission of male and female inpatients in ward


71

2.6.10.2

There are adequate separate toilets for male and female patients in each ward (1 for 6 female bed and 1 for 8 male beds) with wash basins/sinks for the patients.*


2.6.10.3

Safe drinking water is available 24 hours for inpatients


2.6.10.5

Hours/ Time allocated for visitors to meet the inpatients and controlled traffic to prevent cross infection


2.6.10.6

Separate space is available for patients’ visitors (KuruwaGhar).


2.6.11.1

Basic information regarding admitted patients is displayed in a separate board


2.6.11.2

Separate space with privacy dedicated for regular counseling is done for patient and patient party on condition and disease of patient. (See Checklist 2.6).


2.6.12

Appropriate IEC/BCC materials (posters, leaflets etc.) are available in the inpatient ward with focus on infection prevention


72

2.6.13

Admission and discharge registers are available and are being filled completely (HMIS 8.1 and 8.2)


2.6.14.1

PPE are available and used whenever required


2.6.14.2

Each ward has hand sanitizer in visible place for health workers to use before and after touching patients


2.6.14.3

There are well labelled color-coded bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)


2.6.14.4

Hand-washing facility with running water and liquid soap is available and being practiced


2.6.14.5 Needle cutter is used


2.6.14.6

Chlorine solution is available and utilized for decontamination


2.6.14.7

Separate isolation room for any communicable disease patients

Score Standard 2.6

Each row gets a score of 1 if available otherwise 0.

Total Percentage = Total Score/ No of wards (8) x100Plot the scoring based on the scoring chart and fill in the respective standards in tool and checklist

Scoring ChartTotal Percentage Score

0-50 0

50-70 1

70-85 2

85-100 3* For geriatrics ward, commode in toilet and railing on wall in both toilet and bathroom must be kept.

73

Annex 2.6a Furniture and Supplies for inpatient wards(1= Medicine Ward 2= Surgery ward 3= Pediatrics Ward 4= Orthopedics Ward 5=Psychiatry Ward 6= ENT

Ward 7= PNC and Gynecology Ward 8 = Geriatrics Ward)

SN General Items Required Number Score

1 2 3 4 5 6 7 8

1. Working table 1-2

2. Chairs 2

3. Cup board 2

4. Shelves 1

5. Bed side table per bed-1

6. Stools (for visitor) per bed 1

7.

Patient Beds (Metal bed / adjustable head/ mechanical ratchet, 3 X 6 ft.)

As per sanctioned bed(fixed (immobile) for psychiatry ward)(for geriatrics, pneumatic beds/ geriatrics friendly bed)

8. IV stand As per bed


10. Dressing trolley 1

11. Wall Clock 2

12. Oxygen Concentrator 1 per 5 bed

13. Suction machine (foot/electric) 1

14. Refrigerator 1

15. Laryngoscope with blade and batteries 1


17. Self-inflating bag air mask – adult, child, neonate size

1 set

18. BP set and stethoscope (Non-Mercury)

2 sets

19. Thermometer 3-5

20. Baby and adult weighing scale 1 each

21. Nasal speculum set and otoscope 1 each

22. Plaster cutter At least 1

23. Steel drum with sterile cotton 1

74

24. Steel drum with sterile gauze and pad 1

25. Scissors 2

26. Cheatle Forceps with Jar 2

27. Catheter set 2

28. Dressing set At least 10

29.

Mattress with bedcover, pillow with pillow cover, blanket with cover

2-3 set per bed

30. Torch with extra batteries and bulb 2-3

31. Inpatient register/entered per ICD code As per need (1)

32. Inventory Records/ entered per ICD code As per need (1)

33. Cardex files As per bed

34. Waste bins color coded based on HCWM 2014 (MoHP)

1 set per room

Total Score

Maximum Score 32 32 32 33 32 33 32 32

Total percentage= Total Score/Maximum Score x 100

Each row gets a score of 1 if the mentioned medicines are available otherwise 0.

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3










75

Annex 2.6b Medicine and Supplies for Inpatient Ward(1= Medicine Ward 2= Surgery ward 3= Pediatrics Ward 4= Orthopedics ward, 5= Psychiatry ward, 6= ENT ward 7= PNC Ward 8= Geriatrics Ward)

S.No. Medicine and supplies Required No.

Score

1 2 3 4 5 6 7 8

1. Normal Saline Injection 15

2. Dextrose 5% Injection 15

3. Ringers’ Lactate Injection 15

4. Dextrose 5% Normal Saline Injection 15

5. Distilled Water 10

6. IV Infusion Set 10

7. Blood Transfusion Set 5

8. IV Canula (16,18,20,22,24,26Gz) 5 each

9. Gloves (Utility) As per need

10. Mask, Cap, Gowns 1 box

11. Mask, Cap, Gowns As per need

12. Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 30 ml, 50 ml As per need

13. Traction set with different weights As per need

14. Restrain set including belts ( magnetic preferred) As per need

15. Epistaxis management set At least 2

16. Condom tamponade set At least 2

17. Ophthalmoscope* 1

Total Score 13 13 12 13 13 13 13 13

Maximum Score

Total Percentage = Total Score/ Maximum Score x 100

76

Each row gets a score of 1 if the mentioned medicines are available otherwise 0.*Required for neurosurgery and neuro-medicine cases

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3









Annex 2.6c Medicines and Supplies for ER Trolley for Inpatient Ward1= Medicine Ward, 2= Surgery Ward, 3= Pediatrics Ward 4= Orthopedics Ward, 5= Psychiatry Ward, 6= ECT Room 7= ENT ward 8 = PNC Ward 9=Geriatrics Ward

SN Name Required No

Score1 2 3 4 5 6 7 8 9



3. Xylocaine 1% and 2% Injections with Adrenaline 2

4. Xylocaine 1% and 2 % Injections without Adrenaline 2

5. Xylocaine Gel 2

6. Diclofenac Injection 5

7. Hyoscine Butylbromide Injection 5

8. Diazepam injection 2

9. Morphine Injection / Pethidine Injection 2

77


11. Antihistamine Injection 4

12. Dexamethasone Injection 4

13. Ranitidine/Omeperazole Injection 4

14. Frusemide Injection 5

15. Dopamine injection 2

16. Noradrenaline injection 2

17. Digoxin injection 2

18. Verapamil injection 2

19. Amidarone injection 2

20. Glyceryltrinitrate injection 1

21. Labetolol injection 1

22. Sodium bicarbonate injection 2

23. Phenytoin* Injection 5-10

24. Sodium Valporate* Injection 5-10

25. Phenobarbitone* Injection 5-10

26. Levetiraceta* Injection 2-5

27. Ceftriaxone Injection 4


29. Dextrose 25%/50% ampoule 2

30. IV Infusion set (Adult/Pediatric) 2

31. IV Canula (16, 18, 20, 22, 24, 26 Gz) 2 each

32. Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 20 ml, 50 ml 5 each

33. Disposable Gloves (Size 6, 6.5, 7, 7.5) 3 each


35. Sodium chloride-15%w/v and Glycerin-15% w/v (for enema) 5

Total Score

Maximum Score 35 35 31 31 31 31 31 31 31

Total Percentage = Total Score/Maximum ScoreX100

78

Each row gets a score of 1 if all the required number is available otherwise 0.*For neurology and neurosurgery inpatients

Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3





Score for Standard 2.6.8.2.5.1





Area CodeVerificationMaternity

Services2.7

Delivery Services 2.7.1


Maximum Score

2.7.1.1 Availability of delivery service

2.7.1.1.1 Separate pre-labor room/ labor room with privacy is available. 1

2.7.1.1.2 Delivery service is available round the clock 1

2.7.1.1.3 At least one delivery bed is assigned for every 15 maternity beds 1

2.7.1.1.4Labor room has adequate space for accommodating team of health workers during emergencies and easy access to OT

1

2.7.1.1.5 Separate OT for Obstetric Emergencies is available 1

79

2.7.1.2 Trained Human Resource for Delivery Services

2.7.1.2.1 Hospital delivery service has adequate and trained staffing

2.7.1.2.1.1Nurse: pregnant women ratio 1:2 in pre-labor; 2:1 per delivery table and 1:6 in post-natal ward

1

2.7.1.2.1.2 At least one ASBA trained medical officer on duty 1

2.7.1.2.1.3 At least one office assistant is available per shift 1

2.7.1.2.2All staffs- nursing, medical practitioner designated for delivery services are trained skilled birth attendants

1

2.7.1.3 Duty rosters 2.7.1.3 Duty roster to cover 24 hours shift is developed and placed in visible place 1

2.7.1.4 Appropriate use of partograph for decision making

2.7.1.4 Partograph available and being used rationally 1

2.7.1.5 KMC done for low birth weight babies

2.7.1.5 At least 2 KMC chairs available for providing KMC to premature and preterm babies 1

2.7.1.6 Birth certificate prepared and released

2.7.1.6 A formally signed standard birth certificate is issued. 1


2.7.1.7.1

Pre-labor/ during labor patient and patients’ family are adequately given counseling on labor, possible complications and written consent taken

1

2.7.1.7.2Health education on PNC, danger signs of mother and child, Immunization, nutrition, hygiene and family planning is given

1

2.7.1.7.3Postpartum family planning and breastfeeding- early, exclusive and extended counseling is done prior to discharge.

1

2.7.1.8 IEC/BCC 6 materials 2.7.1.8

Appropriate IEC/BCC materials (posters, leaflets etc.) on postnatal care, breastfeeding- early, exclusive and extended, nutrition, immunization are used and available for users

1

2.7.1.9 Furniture, equipment, instrument, medicine and supplies for labor room

2.7.1.9.1 Separate store room for delivery service related logistics 1

2.7.1.9.2

The facility has adequate equipment, instrument and general supplies for delivery services (See Annex 2.7.1a Furniture, equipment, instrument and general supplies for labor room At the end of this standard)

3

2.7.1.9.3

Labor room has medicines and supplies available for delivery services (See Annex 2.7.1bmedicines and supplies for Labor Room At the end of this standard)

3

2.7.1.9.4

Labor room has emergency cart with medicines and supplies available (See Annex 2.7.1c Medicines and Supplies for ER7 Trolley Labor Room At the end of this standard)

3

6 IEC/BCC= Information Education and Communication/ Behavior Change Communication

7 ER= Emergency

80


2.7.1.10.1 Safe drinking water is available 24 hours. 1

2.7.1.10.2Separate toilet for patient is available in pre-labor room and accessible to patient after delivery

1

2.7.1.10.3

There should be maternity waiting homes8

where there is more than 20 deliveries per day and the waiting home must be taken round by every shift with at least one visit (by nurse)

1


2.7.1.11.1 Personal protective equipment are available and used whenever required. 1

2.7.1.11.2 Washable labor room 1

2.7.1.11.3Separate slipper designated for labor room and hand sanitizer placed in visible place for use

1

2.7.1.11.4There are at well labelled color-coded bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1

2.7.1.11.5 Hand-washing facility with running water and liquid soap is available 1


2.7.1.11.7Liquid sodium hypochoride (0.5% Chlorine solution) is available and utilized for decontamination.

1

2.7.1.11.8 Dry gauze and cotton are stored separately in clean containers. 1

2.7.1.11.9 Separate bowls/ bucket for placenta and plastic 1

2.7.1.11.10 Placenta pit is used to dispose placenta. 1


Total Percentage = Total Obtained Score/ 40 x100

Annex 2.7.1a Furniture, equipment, instrument and general supplies for labor room

S.No. Items Required Number Score

1. Delivery bed At least 1 for every 15 beds

2. Clean bed linen Each bed

3. Curtains As per need

4. Clean surface (for alternative delivery position) Available

5. Newborn Resuscitation table 1

6. Light source 1

7. Room Heater 1

8. Baby heater 1 per delivery bed

8 Only for selected remote mountainous area as defined by government

81

9. Refrigerator for labor room 1

Equipment and Instruments

10. BP Set and Stethoscope 1

11. Body Thermometer (Non- mercury) 1

12. Room thermometer 1

13. Fetoscope 2

14. Fetal stethoscope 1

15. Baby weighing scale 1

16. Self-inflating bag air mask - neonatal size 1

17. Mucus extractor with suction tube/(Penguin) 2

18. Doppler 1

19. Vaginal speculum (Sims) 2

20. Neonatal resuscitation kit 1

21. Adult resuscitation kit 1

22. Sterile Delivery Instrument Set (Check each set)

4 sets per delivery beds

22.1

Sponge forceps 2

Artery forceps 2

S/S bowl (Galli pot) 1

S/S bowl (receive placenta) (1-2 litre) 1

Cord cutting Scissors (blunt end) 1

Cord ties/ cord clamp 2

Plastic sheet/ rubber sheet 1

Gauze swabs 4

Cloth squared 3

Kidney tray 1

Peripad/ big dressing pad 2

Leggings 2

Perineal sheet 1

Baby receiving towel 1

Sterile gown 1

23. Suture set (Check each set) 2 sets per delivery beds

82

23.1

Needle holder 1

Sponge holder 1

Suture cutting scissors 1

Dissecting forceps (tooth and plain) 2

Artery forceps 1

Galliport 2

24. Episiotomy set (Check each set) 2 sets per delivery beds

24.1

Episiotomy scissors 1

Needle holder 1

Suture cutting scissor 1

Dissecting forceps(tooth and plain) 2

Artery forceps 1

25. Vacuum set 2

Forceps set for delivery 1

Total Score

Total percentage= Total Score/26x100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard2.7.9.2

Annex 2.7.1b Medicines and Supplies for Labor Room

S.No. Medicines and supplies Required No. Score

Medicines

1. Oxytocin injection (keep in 2-8oC) 20 amp

2. Tranexamic acetate injection 10 amp

3. Ergometrine injection 10 amp

4. Magnesium sulphate injection 50 amp

5. Calcium gluconate injection 10 amp

83



8. Ampicillin injection 10

9. Gentamycin injection 5

10. Metronidazole injection 5

11. Lignocaine injection 2

12. Adrenaline injection 5

13. Ringers’ lactate injection 10

14. Normal saline injection 10

15. Dextrose 5% injection 10

16. Water for injection 5

17. Eye antimicrobial (1% silver nitrate or Tetracycline 1% eye ointment) 2

18. Povidone iodine 5

19. Tetracycline 1% eye ointment 2

20. Paracetamol Tablet 20

21. Nefidipine SL Tablet 5 mg 4 tab

22. Misoprostol Tablet 5 tabs

Supplies

23. Syringes and needles 20

24. IV set 10

25. Spirit (70% alcohol) 1 bottle

26. Steel drum with cotton 1

27. Urinary catheter(plain and folys) 5 each

28. Sutures for tear or episiotomy repair (2.0 chromic catgut) 12 PC

29. Bleach (chlorine-base compound) 2 packets

30. Clean (plastic) sheet to place under mother 4

31. Sanitary pads 1 box

32. Peri-pads Sterile As per need

33. Clean towels for drying and wrapping the baby 5

84

34. Cord ties (sterile) 50

35. Blanket for the baby 5

36. Baby feeding cup 3

37. Impregnated bed net 2

38. Utility Gloves 10 pairs

39. Sterile Gloves 50 pairs

40. Long plastic apron 2

41. Goggles 2

42. Container for sharps disposal 1

43. Needle cutter 1

44. Receptacle for soiled linens 1

45. Bucket for soiled pads and swabs 2

46. Bucket for placenta (5 ltr.) 2

47. Well labelled color coded bins as per HCWM guideline 2014 (MoHP) 1 set

48. Wall Clock 1


50. Maternity register 1-2

51. Birth certificate as per need

52. Partograph As per need

Total Score

Total percentage= Total Score/52 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Score for standard 2.7.1.9.3

85

Annex 2.7.1c Medicines and Supplies for ER Trolley Labor Room

SN Name Required No Score

1. Atropine Injection 10 amp

2. Adrenaline Injection 3vial

3. Xylocaine 1% and 2% Injections with Adrenaline 2vial

4. Xylocaine 1% and 2 % Injections without Adrenaline 2vial

5. Xylocaine Gel 2 tube

6. Diclofenac Injection 5 amp

7. Hyoscine Butylbromide Injection 5amp

8. Diazepam injection 2 amp

9. Morphine Injection / Pethidine Injection 2 amp

10. Hydrocortisone Injection 4vial

11. Chlorpheniramine meliate Injection 4amp

12. Dexamethasone Injection 4vial

13. Ranitidine/Omeperazole Injection 4 amp

14. Frusemide Injection 5 amp

15. Dopamine injection 2 amp

16. Noradrenaline injection 2 amp

17. Digoxin injection 2 amp

18. Verapamil injection 2 amp

19. Amidarone injection 2 amp

20. Glyceryl trinitrate/nitroglycerine injection 10 tab/ 5amp

21. Labetolol injection 5 amp



24. Sodium bicarbonate injection 2 amp

25. Ceftriaxone Injection 4 vials

86

26. Metronidazole Injection 4 bottles

27. Dextrose 25%/ 50% Injection 2


29. IV Canula (16, 18, 20, 22, 24, 26 Gz) 2 each



32. Water for injection 10 ml 10 amp


34.

PPH management Set• (IV canula: 16/18G, IV fluids as per treatment

protocol, IV set, Foley’s catheter, Urobag)• Condom tamponade set- Sponge holder:2, Sim’s

speculum:1, Foley’s catheter:1, Condom:2, IV fluids: NS1, IV set, Thread, Cord Clamp),

• Inj Oxytocin, Tab Misoprostol,

At least 1

35.

Eclampsia management Set(Knee hammer, IV canula: 16/18G, IV fluids, IV set, Foley’s catheter, Urobag, ambu bag, Oxygen, Inj MgSO4: 46 ampoules, Inj lignocaine 2%, Inj Calcium gluconate, Distilled water, Disposable syringe 20ml-1, 10ml-8, Cap Nifedipin- 5mg 4 Cap)

At least 1

Total Score

Total Percentage =Total Score/35X100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


87

Area Code

VerificationMaternity Services 2.7

Maternity Inpatient Service

2.7.2


Maximum Score

2.7.2.1 Space for work

2.7.2.1.1 Separate space for nursing station is available 1

2.7.2.1.2 Separate changing room available for male and female staffs 1

2.7.2.1.3 Separate store room is available 1

2.7.2.1.4 Separate space dedicated for pre-labor, labor and post-labor patients 1

2.7.2.2 Furniture and supplies available and functioning

2.7.2.2

Furniture and supplies to carry out the inpatient services are available and functioning (See annex 2.7.2a Furniture and supplies for maternity inpatient wards At the end of this standard ) (including nursing station)

3

2.7.2.3 Medicine and supplies available

2.7.2.3

Medicine and supplies to carry out the inpatient services are available General Ward (See Annex 2.7.2bmedicine and supplies for maternity inpatient wards At the end of this standard)

3

2.7.2.4 Nursing and support staff for inpatient service

2.7.2.4.1Adequate numbers of nursing staff are available in ward per shift (nurse patient ratio 1:6 in general ward)

1

2.7.2.4.2 At least one trained office assistant per shift in each ward 1

2.7.2.5 Duty rosters 2.7.2.5 Duty roster of doctors, nurses, paramedics and

support staffs kept visibly in nursing station 1

2.7.2.6 Communication 2.7.2.6


1

2.7.2.7 Emergency management of inpatients

2.7.2.7.1All staffs in wards are trained for BLS and oriented about emergency code 001 or blue code

1

2.7.2.7.2

At least one emergency trolley with emergency medicine available in ward (Annex 2.7.2c Medicine and Supplies for ER Trolley for Maternity In patient Ward At the end of this standard)

3

2.7.2.7.3 At least one defibrillator in immediate accessible area 1

88

2.7.2.8 Physical facilities for patient

2.7.2.8.1 Separate area designated for admission of male and female inpatients in general ward 1

2.7.2.8.2 There are adequate toilets for male and female patients in each ward (1 for 6 female bed) 1

2.7.2.8.3 Safe drinking water is available 24 hours for inpatients 1

2.7.2.8.4Hours/ Time allocated for visitors to meet the inpatients and controlled traffic to prevent cross infection

1

2.7.2.8.5 Separate space is available for patients’ visitors (Kuruwa Ghar). 1

2.7.2.9 Communication 2.7.2.9 Basic information regarding admitted patients

is displayed in a separate board 1

2.7.2.10 IEC/BCC Materials 2.7.2.10

Appropriate IEC materials (posters, leaflets etc.) are available in the inpatient ward with focus on infection prevention

1


2.7.2.11Admission and discharge registers are available and are being filled completely (HMIS 8.1 and 8.2)

1


2.7.2.12.1 Personal Protective equipment are available and used whenever required 1

2.7.2.12.2Each ward has hand sanitizer in visible place for health workers to use before and after touching patients

1

2.7.2.12.3There are well labelled color-coded bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1

2.7.2.12.4 Hand washing facility with running water and liquid soap is available and being practiced 1

2.7.2.12.5 Needle cutter is used 1

2.7.2.12.6 Chlorine solution is available and utilized for decontamination 1



Annex 2.7.2a Furniture and Supplies for Maternity Inpatient wards

SN General Items Required No. Score


2. Chairs 2

3. Cup board 2

4. Shelves 1


89


7. Patient Beds (Metal bed / adjustable head/ mechanical ratchet, 3 X 6 ft.)

As per sanctioned bed




11. Wall Clock 2

12. Oxygen Concentrator 1 per 5 bed




16. Self-inflating bag air mask – adult, child, neonate size 1 set

17. BP set and stethoscope (Non-Mercury) 2 sets

18. Thermometer 3-5




22. Scissors 2


24. Catheter set 2

25. Dressing set 2

26. Mattress with bedcover, pillow with pillow cover, blanket with cover

2-3 set per bed


28. Inpatient register as per ICD code As per need

29. Inventory Records As per need


31. Waste bins color coded based on HCWM guideline 2014 (MoHP)

1 set per room

Total Score

Total percentage= Total Score/31x 100

90


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.7.2b Medicine and Supplies for Maternity Inpatient Ward

S.No. Medicine and supplies Required No. Score







7. IV set 5

8. IV Catheter 18G,20G,22G,24G,26G 5 each

9. Gloves (Utility) 1 box


11. Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 30 ml, 50 ml

As per need

Total Score

Total Percentage = Total Score/ 11 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


91

Annex 2.7.2c Medicines and Supplies for ER Trolley Maternity Inpatient Ward





4. Xylocaine 1% and 2% Injections without Adrenaline 2

5. Xylocaine Gel 2



8. MetharginInjecyion 5


10. Morphine Injection / Injection Pethidine 2


12. Antihistamine Injection 4









21. Glyceryl trinitrate/ notroglycerine 1o tab/ 5 amp


23. Magnesium sulphate injection 30

24. Calcium gluconate injection 2




28. Dextrose 25% / 50% Injection 2

29. IV Infusion set (Adult/Pediatric) 5 each

92

30. IV Canula (16, 18, 20, 22, 24, 26 Gz) 2


32. Disposable Gloves 6, 6.5, 7, 7.5 5 each



Total Score

Total Percentage = Total Score/34 X100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Area Code

VerificationMaternity Service 2.7

Birthing center service 2.7.3

Components Standards Obtained Score Maximum Score

2.7.3.1 Birthing center available 2.7.3.1

Dedicated block for birthing center with health facility having more than 500 deliveries per month

1

2.7.3.2 Space for work

2.7.3.2.1 Separate space for nursing station is available 1

2.7.3.2.2 Separate changing room available for male and female staffs 1

2.7.3.2.3 Separate store room is available 1

2.7.3.2.4 Separate space dedicated for pre-labor, labor and post-labor patients 1

2.7.3.3 Furniture and supplies available and functioning

2.7.3.3

Furniture and supplies to carry out the inpatient services are available and functioning (See Annex 2.7.3aFurniture and supplies for birthing center At the end of this standard)

3

93

2.7.3.4 Medicine and supplies available

2.7.3.4

Medicine and supplies to carry out the inpatient services are available General Ward (See Annex 2.7.3b Medicine and supplies for Birthing Center At the end of this standard)

3

2.7.3.5 Nursing station 2.7.3.5

There is a set of at least one table and two chairs in the nursing station and shelves for storage of charts and inpatient forms and formats

1

2.7.3.6 Nursing staff for inpatient service

2.7.3.6 Hospital delivery service has adequate and trained staffing

2.7.3.6.1

Nurse/Midwife: pregnant women ratio 1:2 in pre-labor; 2:1 per delivery table and 1:6 in post-natal ward

1

2.7.3.6.2 At least one ASBA trained medical officer on duty 1

2.7.3.6.3 At least one office assistant is available per shift 1

2.7.3.6.4

All staffs- nursing, medical practitioner designated for delivery services are trained skilled birth attendants/Midwife

1

2.7.3.7 Duty rosters 2.7.3.7

Duty roster to cover 24 hours shift is developed and placed in visible place

1



1

2.7.3.9 Emergency management of inpatients

2.7.3.9.1All staffs in wards are trained for BLS and oriented about emergency code 001 or blue code

1

2.7.3.9.2

At least one emergency trolley with emergency medicine available in ward (See Annex 2.7.3c Medicine and Supplies for ER Trolley for Maternity Inpatient Ward At the end of this standard)

3

2.7.3.9.3 At least one defibrillator in immediate accessible area 1

2.7.3.10 Physical facilities for patient

2.7.3.10.1Separate area designated for admission of male and female inpatients in general ward

1

2.7.3.10.2There are adequate toilets for male and female patients in each ward (1 for 6 female bed)

1

2.7.3.10.3 Safe drinking water is available 24 hours for inpatients 1

2.7.3.10.4Hours/ Time allocated for visitors to meet the inpatients and controlled traffic to prevent cross infection

1

2.7.3.10.5 Separate space is available for patients’ visitors (Kuruwa Ghar). 1

94


Basic information regarding admitted patients is displayed in a separate board

1

2.7.3.12 IEC/BCC Materials 2.7.3.12

Appropriate IEC materials (posters, leaflets etc.) are available in the inpatient ward with focus on infection prevention

1


2.7.3.13Admission and discharge registers are available and are being filled completely (HMIS 8.1 and 8.2)

1


2.7.3.14.1 PPE are available and used whenever required 1

2.7.3.14.2

Each ward has hand sanitizer in visible place for health workers to use before and after touching patients

1

2.7.3.14.3

There are well labelled color-coded bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1

2.7.3.14.4Hand-washing facility with running water and liquid soap is available and being practiced

1



Standard 2.7.3Total Score 37

Total Percentage (Total Score/ 37 x100)

Annex 2.7.3a Furniture and Supplies for Birthing Center



2. Chairs 2

3. Cup board 2

4. Shelves 1



7.Patient Beds (Metal bed / adjustable head/ mechanical ratchet, 3 X 6 ft.)

As per sanctioned bed


95



11. Wall Clock 2

12. OxygenConcentrator 1 per 5 bed




16. Self-inflating bag air mask – adult, child, neonate size 1 set

17. BP set and stethoscope (Non-Mercury) 2 sets

18. Thermometer 3-5




22. Scissors 2


24. Catheter set 2

25. Dressing set 2

26. Delivery set At least 5

27. Delivery forceps set At least 2

28. Delivery vacuum set At least 2

29.Mattress with bedcover, birthing pillow with pillow cover, blanket with cover

1 set per bed

30. Birthing balls At least 3


32. Inpatient register/entered per ICD code As per need (1)

33. Inventory Records/ entered per ICD code As per need (1)


35. Waste bins color coded based on HCWM guideline 2014 (MoHP) 1 set per room

Total Score


96


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.7.3b Medicine and Supplies for Birthing Center

S.No. Medicine and supplies Required No. Score







7. IV set 5

8. IV Canula (16G,18G,20G,22G,24G,26G) 5 each

9. Gloves (Utility) 1 box


11. Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 30 ml, 50 ml As per need

Total Score


97


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.7.3c Medicines and Supplies for ER Trolley Labor Room


1. Atropine Injection 10 amp

2. Adrenaline Injection 3vial

3. Xylocaine 1% and 2% Injections with Adrenaline 2vial

4. Xylocaine 1% and 2% Injections without Adrenaline 2vial

5. Xylocaine Gel 2 tube

6. Diclofenac Injection 5 amp

7. Hyoscine Butylbromide Injection 5amp

8. Diazepam injection 2 amp

9. Morphine Injection / Pethidine Injection 2 amp

10. Hydrocortisone Injection 4vial

11. Antihistamine Injection 4amp

12. Dexamethasone Injection 4vial

13. Ranitidine/Omeperazole Injection 4 amp

14. Frusemide Injection 5 amp

15. Dopamine injection 2 amp

16. Noradrenaline injection 2 amp

17. Digoxin injection 2 amp

18. Verapamil injection 2 amp

19. Amidarone injection 2 amp

20. Glyceryl trinitrate/ nitroglycerine injection 10 tab/ 5amp

21. Labetolol injection 5 amp

98



24. Sodium bicarbonate injection 2 amp

25. Ceftriaxone Injection 4 vials

26. Metronidazole Injection 4 bottles

27. Dextrose 25% / 50% Injection 2


29. IV Canula (16, 18, 20, 22, 24, 26 Gz) 2 each



32. Distilled Water 10 amp


34.

PPH management Set• (IV canula: 16/18G, IV fluids as per treatment

protocol, IV set, Foley’s catheter, Urobag)• Condom tamponade set- Sponge holder:2,

Sim’s speculum:1, Foley’s catheter:1, Condom:2, IV fluids: NS1, IV set, Thread, Cord Clamp),

• Inj Oxytocin, Tab Misoprostol,

At least 1

35.

Eclampsia management Set(Knee hammer, IV canula: 16/18G, IV fluids, IV set, Foley’s catheter, Urobag, ambu bag, Oxygen, Inj MgSO4: 46 ampoules, Inj lignocaine 2%, Inj Calcium gluconate, Distilled water, Disposable syringe 20ml-1, 10ml-8, Cap Nifedipin- 5mg 4 Cap)

At least 1

Total Score

Total Percentage =Total Score/35X100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


99

Area Code

VerificationSurgery / Operation Services

2.8


Maximum Score

2.8.1 Time for surgical services/ operations

2.8.1.1.1 Routine minor and intermediate surgeries available on scheduled days 1

2.8.1.1.2 Routine major surgeries available on scheduled days 1

2.8.1.2 Emergency surgeries available round the clock 1

2.8.1.3 At least four functional operating rooms 1

2.8.2 Staffing

2.8.2.1

For one surgery, at least a team is composed of: MS/MDGP with one trained medical officer, two OT trained nurse (one scrub and one circulating), one Anesthesiologist/MDGP, one anesthesia assistant and one office assistant ( for cleaning and helping)

1

2.8.2.2

For overall management of operation theatre, there is one OT nurse (with minimum bachelors degree) assigned as OT in-charge

1

2.8.2.3At least two nurses in pre-anesthesia area for receiving and transferring of the patient and

1

2.8.2.4At least two ICU trained nurses for post anesthesia care for receiving patient after OT

1

2.8.3 Surgical services available

2.8.3.1General Surgeries (See Annex 2.8a List of Minimum Surgeries Available At the end of this standard)

3

2.8.3.2

Obstetrics and Gynecology Surgeries (See Annex 2.8b List of Minimum Obstetrics and Gynecology Surgeries Available At the end of this standard)

1

2.8.3.3

Orthopedic Surgeries (See Annex 2.8c List of Minimum Orthopedics Surgeries Available At the end of this standard)

3

2.8.3.4ENT surgeries available (Annex 2.8d Types of ENT Surgeries Available At the end of this standard)

3

100

2.8.4 Patient counseling and

2.8.4.1 Indications and reviews the clinical history and physical examination is documented 1

2.8.4.2 Pre-anesthesia checkup done for routine surgeries and documented 1

2.8.4.3Informed consent is taken before surgery; patients and caretakers are given appropriate counseling about the surgery

1

2.8.5 WHO safe surgery checklist 2.8.5 The WHO Safe Surgery Checklist is

available in OT and used 1

2.8.5 Patient preparation 2.8.5

Preoperative instructions for patient preparation are given and practiced with routine pre-anesthesia check up

1

2.8.7 Operation Theatre/Room

2.8.7.1OT has appropriate physical set up (See Annex 2.8e Physical Set Up for OT At the end of this standard)

3

2.8.7.2

Each operating room has general equipment, instruments and supplies available (See Annex 2.8f Furniture, Equipment, Instruments and Supplies for OT At the end of this standard)

3

2.8.7.3

Each operating room has medicines and supplies available (See Annex 2.8g General Medicine and Supplies for OT At the end of this standard)

3

2.8.7.4

Surgical sets for minimum list of the surgical services available (See Annex 2.8h Surgical sets for Minimum list of the surgical procedures At the end of this standard)

3

2.8.8.1 Availability of anesthesia Services

2.8.8.1 Anesthesia service is provided following the standards operating procedure

2.8.8.1.1 Local anesthesia 1

2.8.8.1.2 Regional anesthesia 1

2.8.8.1.3 Spinal anesthesia 1

2.8.8.1.4 General anesthesia 1

2.8.8.2Equipment, instruments and supplies for anesthesia

2.8.8.2

Equipment, instrument and supplies for anesthesia available (See Annex 2.8i Equipment, Instrument and Supplies for Anesthesia At the end of this standard)

3

2.8.8.3 Medicine and supplies for anesthesia

2.8.8.3

Medicine and supplies for anesthesia available (See Annex 2.8j Medicine and Supplies for Anesthesia At the end of this standard)

3

101

2.8.8.4 Staffing and supervision

2.8.8.4.1 Anesthesia should be provided, led, or overseen by an anesthesiologist

1

2.8.8.4.2

When anesthesia is provided by non-physician anesthesiologists, these providers should be directed and supervised by anesthesiologists/ MDGP

2.8.9 Pre anesthesia and post-operative care

2.8.9.1

Dedicated space for pre-anesthesia assessment and post-anesthesia recovery with patient bed, IV stand, IV cannula, fixing tapes, infusion sets, burette sets, syringes, three-way stop cocks and at least one cardiac monitor

1

2.8.9.2Separate area designated for post-operative care to stabilize the patient after surgery

1

2.8.9.3Staffs are specified for the post-operative care including close monitoring of the vital signs and observation of patient

1

2.8.9.4Patients’ pain management is prioritized, measures well documented and analgesic effect followed up

1

2.8.9.5

Patient undergoing surgical procedure is done pre- anesthetic check-up, continuously monitored during and at least 2 hours post- anesthesia

1

2.8.9.6

Adequate information shared for patient care and patient followed by at least one nurse/doctor for hand over or transfer of patient within or outside the hospital

1

2.8.10 Recording 2.8.10.1

Recording is done for all surgeries procedure including observation, management and complications if any

1

2.8.10.2 Records of all anesthetic procedures are kept and reported 1

2.8.11 Infection prevention protocol is strictly followed by all staffs in operation theatre/room

2.8.11.1 Hand hygiene 2.8.11.1

Hand-washing and scrubbing facility with running water and soap is available and being practiced with elbow tap

1

2.8.11.2 Appropriate PPE 2.8.11.2

Gowns and sterile drapes for patients and sterile gown for surgery team are available and used whenever required.

1

2.8.11.3 Fumigation 2.8.11.3 Fumigation is done at least once a week in

the OT on Saturdays and as per need 1

2.8.11.4 Disinfection of instruments

2.8.11.4 High Level Disinfection (e.g. Cidex) facility is available and being practiced. 1

2.8.11.5 High Wash 2.8.11.5 High wash is done at least once a month in OT 1

2.8.11.5 Appropriate segregation of waste

2.8.11.6Separate colored waste bins based on HCWM guideline 2014 (MoHP) are available and used

1

102

2.8.11.7 Disposal of sharps 2.8.11.7 Needle cutter is used. 1

2.8.11.8 Cleaning 2.8.11.8 Chlorine solution is available and utilized for decontamination. 1


Total Percentage= Total Obtained Score/ 62 x 100

Annex 2.8a General Surgeries Available

S.No. List of the surgeries available (minimum) Score

Minor

1. Incision & Drainage under Local Anesthesia

2. Excision of cysts, ganglion, lump, lymhnode, lipoma, skin papilloma, corn under LA

3. Excision of ingrowing toe nail under digital block

4. Wound debridement

5. Skin suturing < 5cm size

6. Foreign Body removal under LA

7. Repair split ear

8. True cut biopsy

9. Circumcision Under LA

10. Haemorrhoid banding

Intermediate

11. Chest tube insertion under LA Chest tube insertion under LA

12. Eversion of sac for hydrocele (EVS)

13. Herniotomy under IVA

14. Mesh Repair / Darn Repair (under LA/SA)

15. Amputation

16. Split Skin Graft(SSG)

17. Large wound dressing / debridement under IVA/SA

18. Chest tube insertion under IVA

19. Circumcision under IVA

20. I & D under IVA eg. Perineal abscess

21. Release of tongue tie

103

22. Fistulotomy

23. Haemorrhoidectomy

24. Vasectomy

Major

25. Exploratory laparotomy

26. Appendectomy

27. Exploration for obstructed hernia

28. Mesh repair incisional hernia

29. Open cholecystectomy

30. Ileostomy / colostomy formation

31. Open pyelolithotomy

32. Open ureterolithotomy

33. Open suprapubic cystolithotomy

34. Oophorectomy

Total score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8b Types of Obstetrics and Gynecology Surgeries Available

Minimum list of Obstetrics and Gynecology Surgeries Available Score

Intermediate

I & D under IVA eg. Breast abscess

Removal of product of conception and surgical Abortion

104

Cervical Tear Repair

Major

1. Caesarean Section

2. Minilap

3. Vaginal hysterectomy

4. Abdominal hysterectomy

5. Oophorectomy

6. Tumor removal (Obstetrics and gynaecological)

7. Exploratory laparotomy

Total Score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8c Types of Orthopedics Surgeries Available

S.N. Minimum list of Orthopedic Surgeries Score

1. POP + Immobilization without anesthesia

2. POP + cast under anesthesia

3. Hip Spica cast

4. Joint aspiration

5. Intralesional steriod injection

6. Skin traction

7. Gallows traction

105

8. Skeletal Traction

9. Reduction of shoulder, elbow, small joints dislocation

10. Reduction of hip and knee dislocation

11. Extensor Tendon Repair

12. Flexor Tendon Repair

13. Amputation under LA and/or sedation

14. Simple implant removal

15. Soft tissue benign tumor excision

16. Trigger finger Release

17. DeQuervain's Release

18. Carpal Tunnel Release

19. Dupuytren's Contracture Surgery

20. CRPP (small joints)

21. CRPP (supracondylar fractures)

22. CRPP (distal radial fractures)

23. CRPP (proximal humerus)

24. Amputation (life-saving) under GA

25. Rush Nailing

26. Arthrotomy small joints

27. Arthrotomy large joints

28. ORIF Lateral condyle fracture

29. ORIF Supracondylar fracture

30. ORIF Short Long Bones

31. ORIF olecranon process/patella

32. ORIF Long Long Bones

33. ORIF ankle/knee/wrist/elbow/shoulder/hip

34. External Fixation

35. Radial head excision

36. IMIL Nailing Tibia/Femur

37. PFN

38. MIPO various bones

39. DHS/DCS/CCS hip

40. HRA

106

41. Arthroscopy

42. Discectomy

43. Fasciotomy

44. Decompression surgery for Acute osteomyelitis

Total score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8d Types of ENT Surgeries Available

Minimum list of ENT Surgeries Available Score

Emergency ENT Surgeries

1. Tracheostomy

2. Foreign Body removal (including bronchsocopy)

3. Ludwigs’ Angina

Routine ENT Surgery

4. Myringoplasty /Tympanoplasty

5. Mastoid drill / Motor with burrs

6. Stapes surgery

7. Rigid oesophagoscopy

107

8. Tonsil adenoid

9. Endosopic sinus surgery and FESS

10. Septoplasty/ Rhinoplasty

Total score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8d Physical Set Up for OT

SN Physical Set Up Score

Separate room designated for OT with recovery roomSpace designated for changing room for male and female staffs separately

Lockers for storage of the belongings of staffs

Separate shelves for storage of clean and dirty shoes at the entrance of the OT area demarked with red lineSpace designated with sink facilitated with elbow tap for scrubbing

Designated space for tea room

Separate bathroom with at least one universal toilet for OTScrub basins with running water

Utility basins (at least 4)

Total Score

Total percentage= Total Score/ 9 x 100

108


Scoring chartTotal percentage Score0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8eFurniture, Equipment, Instruments and Supplies for each OT Room

SN General Equipment and Instruments for OT Standard Quantity for each OT room Score

Wheel chair foldable, adult size 2

Stretcher 2

Patient trolley 2

Cupboards and cabinets for store 2

Working desk for anesthesia, nursing station, gowning 1 each

OT Table- universal type/ with wedge to position patient (*Radioluscent OT table with orthopedic attachment including C-arm for orthopedics)

At least 1

Examining table 1

Mayo Stand with tray At least 2

Operation theatre lights At least 1

Medical Microscope for Surgeries (*for ENT) At least 1*

Colposcope (*for Obstetrics and Gynecology Surgery) At least 1 *

Ultra violet light source At least 1

Central suction supply Available

Central oxygen supply Available

Electronic suction machine/ Foot-operated suction machine At least 2

Oxygen concentrator/ Oxygen Cylinder At least 2

Refrigerator / cold box At least 1 each

Anesthesia machine with cardiac monitor At least 1

Defibrillator At least 1

Cautery/Diathermy machine At least 1

Oxygen concentrator/ Oxygen Cylinder At least 1

Baby warmer At least 1

Baby weight machine At least 2

109

Anesthesia trolley At least 2

Instrument trolley At least 1

BP instrument with stethoscope At least 1

Monitor with BP cuff in each anaesthsia machine At least 1

Digital Thermometer At least 1

Steel Drum for guaze 2

Steel Drum for Cotton 2

Tourniquet, latex rubber, 75 cm 4

Kidney tray (600cc) 4

Covered instrument trays 8

Mackintosh sheet As per need

Lead gown 2 sets

Bowl stand 4

Chele forceps in jar 8

Drapes for abdominal site (laparotomy sheet, table cover, hook towel, mayo cover, plastic sheet, tetra)

As per need

Drapes for perineal region(Laparotomy sheet, table cover, hook towel, mayo cover, plastic sheet, tetra, leggings)

As per need

Packing towel double wrapper As per need

Sterile gloves (6,6.5,7,7.5,8) As per need

Towels/ eye hole As per need

Masks and caps, gown As per need

Torch light and batteries 2set

Foot steps 4

Wall clock In each Room

Waste bucket for scrub nurse 4

IV stand 4

Leak proof sharp container 1 in each OT Room

Generator back up for OT 1

Color coded waste bins (based on HCWM guideline 2014 (MoHP))

1 set per Room

OT dress for staffs As per need

OT slippers As per need

Total Score

Total percentage= Total/ 53x 100

110


Scoring ChartTotal percentage Score0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8f Medicine and Supplies for OT


Midazolam Injection 5 vials

Hydrocortisone Powder for Injection 100mg 10 vial

Frusemide Injection 2 ampules

Dopamine Injection 5 vials

Transemic Acetate Injection 2 ampules

Hydralizine Injection 5 vials

Calcium Gluconate Injection 10ml X 2 ampules

Magnesium sulphate Injection 0.5 gms X 28

Oxytocin Injection 10 Ampules

Dextrose (25%) / (50%) Injection 2 ampules

Naloxone Injection 1 ampule

Aminophyline Injection 2 ampules

Chloropheniramine Injection 2 ampules

Mephentine Injection 1 vial

IV Fluids- Ringers Lactate / Normal Saline/ Dextrose 5% Normal Saline/ Dextrose 5% 6 bottles each

IV infusion Set 8

IV Canula 22G/20G/18G 4 each

Total Score


111


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8g Minimum List of Surgical Sets


Catheter set At least 5 Set

Suture set At least 5 Set

Dressing set of different size (small, medium, large) At least 2 each

Incision and drainage set At least 5 Set

Tracheostomy Set At least 5 Set

Appendectomy set At least 2 Set

Caesarian section set At least 5 Set

Hernia repair set At least 2 Set

Manual Vacuum Aspiration Set with Canulla and Aspirator of different size At least 2 Set

Laparotomy set At least 2 Set

Vasectomy set At least 2 Set

Minilap set At least 2 Set

Open cholecystectomy set At least 2 Set

Ileostomy / colostomy Set At least 1 Set

Open pyelolithotomy Set At least 1 Set

Open ureterolithotomy Set At least 1 Set

Open suprapubic cystolithotomy Set At least 1 Set

Oophorectomy Set At least 1 Set

Orthopedics Basic Surgical Set At least 2 Set

K wire set At least 2 set

IM Nailing set At least 2 set

112

Hemi-Replacement Arthoplasty set At least 1 set

External fixation set At least 1 set

Amputation set (bone saw, bone file) At least 1 set

Bronchoscope At least 1set

Myringoplasty /Tympanoplasty Set At least 1 set

Mastoid drill / Motor with burrs At least 1 set

Stapes surgery set At least 1 set

Rigid oesophagoscope At least 1 set

Tonsil adenoid set At least 1 set

Endosopic sinus surgery and FESS set At least 1 set

Septoplasty/ Rhinoplasty set At least 1 set

Total Score

Total Percentage= Total Score/31x100Each row gets a score of 1 if all the required number is available otherwise 0

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8hEquipment, Instruments and Supplies for Anesthesia

S.No. List of equipment, instruments and supplies for anesthesia Required Number Score

Supply of oxygen (e.g., oxygen concentrator, cylinders or pipeline) with regulator and flow meter

At least 2 oxygen concentrator

Oropharyngeal airways (Size 000, 00, 0, 1, 2, 3, 4) At least 2 each

Anesthesia face masks (Size 0, 1, 2, 3, 4) At least 2 each

Laryngoscope, Mc Coy's curved blade and Miller's straight blade (small, medium and large sizes for both adult and pediatric patients)

At least two

113

Endotracheal tubes, cuffed, uncuffed, different sizes (Sizes 2.5 - 8.0 ID)

At least two of each size

Intubation aids (Magillsforcep of small and large size, bougie, stylets of small and large size)

As per need

Suction device and suction catheters of different sizes (Size 8 -16 Fr) As per need

Adult and pediatric self inflating bags (Size 2L, 1L, 0.5L) As per need

Bain's breathing circuit At least 2

Pediatric breathing circuit: Ayre's T-piece At least 2Equipment for intravenous infusions and injection of medications for adult and pediatric patients (IV stand, IV canula, fixing tapes, infusion sets, blood transfusion sets, burette sets, syringes, three-way stop cocks)

As per need

Equipment for spinal anesthesia or regional blocks (e.g., a set of spinal needle 25/26 G, small bowl, 5-10ml syringe, sponge holding forceps, kidney tray, large eye towel, cotton pieces, gauze pieces)

As per need

Examination (non-sterile) gloves As per need

Sterile gloves As per need

Pulse oximeter At least 2

Access to a defibrillator At least 1

Stethoscope At least 2

Sphygmomanometer with appropriate sized cuffs for adult and pediatric patients As per need

Non-invasive blood pressure monitor with appropriate sized cuffs for adult and pediatric patients

As per need

Anesthesia machine with inspired oxygen concentration monitor, anti-hypoxia device to prevent delivery of a hypoxic gas mixture, system to prevent misconnection of gas sources (e.g., tank yokes, hose connectors), automated ventilator with disconnect alarm.

At least 1

Electrocardiogram - three leads As per need

Temperature monitor (intermittent) As per need

Total Score


114


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.8iMedicines for Anesthesia

S.No. List of Medicines Required Number Score

Preoperative medications

1. Ranitidine Injection 5

2. Metoclopramide Injection 5

3. Aluminium hydroxide or magnesium trisilicate suspension 5


5. Diazepam Tablet 5

Intraoperative medications

6. Ketamine Injection 3


8. Opioid analgesics injections ( Morphine, Pethidine, Fentanyl) 2 each

9. Lignocaine 2% Injection for IV infusion 2

10. Lignocaine Inj 1%, 2% with or without Adrenaline 1:200000 2

11. Thiopental Powder 500mg As per need

12. Propofol Injection As per need

13. Appropriate inhalational anesthetic (e.g., Halothane, Isoflurane, Sevoflurane) As per need

14. Succinylcholine Injection As per need

15. Appropriate non-depolarizing muscle relaxant ( pancuronium, vecuronium, rocuronium, atracurium)

As per need

16. Neostigmine Injection As per need

17. Atropine Injection / Glycopyrolate Injection 10/10

18. Bupivacaine Heavy 0.5% 5

115

Intravenous fluids

19. Water for injection As per need

20. Normal saline / Ringer’s lactate As per need

21. 5% Dextrose / Dextrose normal saline As per need

22. 1/5Dextrose 1/3Normal saline As per need

23. Mannitol 20% Injection As per need

24. Haemaccel Injection / Gelafusine Injection / Voluven Injection As per need

Resuscitative medications

25. Dextrose 25%/ 50% Injection 5

26. Mephenteramine or Ephedrine Injection 5



29. Amiodarone injection 5

30. Hydrocortisone injection 5

31. Dexomethasone injection 5

32. Chlorpheniramine injection 5

33. Calcium gluconate injection 5

34. Beta-blockers (Metoprolol, Labetolol, Esmolol) Injection As per need

35. Naloxone Injection 5

Post-operative medications

36. Morphine Injection As per need

37. Pethidine Injection As per need

38. Tramadol Injection As per need

39. Pentazocine Injection As per need

40. Paracetamol Injection 1gm, Suppository 125mg As per need

41. Diclofenac Injection As per need

42. Ketorolac Injection As per need

43. Promethazine Injection As per need

44. Ondansetron Injection As per need

45. Gabapentin Injection As per need

Other medications

46. Magnesium Injection As per need

116

47. Salbutamol Injection (for inhalation) As per need

48. Ipratropium bromide Injection (for inhalation) As per need

49. Furosemide Injection As per need

50. Glyceryl trinitrate/nitroglycerine Injection As per need

51. Sodium nitroprusside Injection As per need

52. Heparin Injection As per need

53. Aminophylline Injection As per need

Total Score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


117

Area Code

VerificationHemodialysis service

2.9


Maximum Score


2.9.1.1 Hemodialysis service is available from 9 am to 5 pm and appointments of patient scheduled 1

2.9.1.2 Emergency hemodialysis is available round the clock 1

2.9.1.3 Under privilege citizen facilities as per norms of government of Nepal 1

2.9.2 Space for hemodialysis service

2.9.2.1Separate block/rooms designated for hemodialysis with space for at least two hemodialysis beds and machines and a working.

1

2.9.2.2The dialysis station is easily accessible in time of emergency and have adequate space for resuscitation to be carried out.

1

2.9.2.3

There is designated space for dialyzer reprocessing and proper cleaning and preparation of dialysers for reuse done based on protocol

1

2.9.2.4

There is designated space for medicine preparation and storage of medicines, equipment, instruments and supplies in shelves with separate dry and wet storage shelves

1

2.9.2.5Separate bed is available for rest to patient after dialysis or to give injection on OPD as erythropoietin, cyclophosphamide, and others.

1

2.9.3 Staffing

2.9.3.1

There should be at least one haemodialysis trained medical officer with on call MD Internal Medicine or Nephrologist and one nurse per two dialysis machine per shift

1

2.9.3.2All hemodialysis staffs are trained on BLS, ACLS and basic maintenance of hemodialysis machine.

1

2.9.3.3Biomedical equipment trained technician is available any time in case of technical emergencies

1

2.9.4 Patient counseling

2.9.4.1

Counselling to the patient and attendant is done by multi-disciplinary team to adhere the patient to the treatment therapy including dietary counseling and follow up

1

2.9.4.2Proper care and monitoring of the Vascular access is done during treatment and patient counseled about its care

1

118

2.9.5 Equipment, instruments, drugs and consumables available

2.9.5.1 Dialysis machines is equipped with monitors and audio-visual alarms to ensure safe dialysis. 1

2.9.5.2Dedicated hemodialysis area and dedicated dialysis machines for patients with hepatitis B, Hepatitis C and PLHA

1

2.9.5.3

Adequate medical equipment and instruments available. (See Annex 2.9aList of medical equipment and instruments for hemodialysis At the end of this standard)

3

2.9.5.4Adequate drugs and consumables available (See Annex 2.9b Medicines and supplies for hemodialysis At the end of this standard)

3

2.9.6 Physical Facility

2.9.6.1Product water is free from harmful chemicals and bacterial contamination with reverse osmosis done

1

2.9.6.2 Water used to prepare the dialysate has colony count of less than 100CFU/ml. (AAMI Standard) 1

2.9.6.3Recommended water quality by provision of water analysis for bacteria at least monthly and chemical at least six monthly.

1

2.9.6.4 Endotoxin test of RO water and dialysate is performed in annual basis. 1

2.9.6.5Power back up supply is ensured in hemodialysis unit at least for reverse osmosis and dialysis machine

1

2.9.6.6 Plumbing is installed in manner as to prevent back flow of the dialysate drainage 1

2.9.6.7 There is adequate light, well ventilation and suitable temperature maintained 1

2.9.6.8 Separate toilets for male and female staff with at least one universal toilet 1

2.9.7 Inventory maintained 2.9.7 Biomedical equipment log book is maintained

along with preventive maintenance records 1

2.9.8 Handover and takeover of critical patients

2.9.8

There is provision of transporting patient for transfer/referral in safe manner accompanied by at least one mid-level health worker and if needed medical officer

1


2.9.9.1 Medical record is maintained in register and digital format. 1

22.9.9.2 Dialysis schedule of the patient is maintained in board along with time. 1

119

2.9.10 Infection control measures followed in hemodialysis service

2.9.10.1 Personal protective equipment as gown, mask, face shield as per requirement. 1

2.9.10.2 Dialyzers and AV blood lines of PLHA, Hepatitis B and Hepatitis C positive is discarded after each use.

1

2.9.10.3 Rinsing of machine is done after each shift and disinfection is done as per protocol 1

2.9.10.4 Dedicated shoes and gown is available in entrance of dialysis unit. 1

2.9.10.5 Autoclave of infected waste before disposal 1

2.9.10.6There are colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1

2.0.10.7 Hand-washing facility with running water and liquid soap is available for practitioners 1


2.9.10.9 Chlorine solution is available and utilized for decontamination. 1



Annex 2.9a Medical equipment and instrument for hemodialysis

S.N. Medical equipment and instrument Required No Score

1 Hemodialysis machine at least 2

2 Blood Pressure Apparatus 2

3 Stethoscope 2

4 Thermometer(Patient and Refrigerator) 2

5 Glucometer 2

6 Hemodialysis set 2

7 Curtain as per need

8 Wheel Chair at least 2

9 Stretcher at least 1

10 Bed as least 2

11 Bed side Tray 1 in each bed

12 Standby Rechargeable light 1

13 Hygrometer 1

120

Resuscitation set at least 1

14 Suction Apparatus at least 1

15 Oxygen cylinder with flow meter,nasal prongs and mask or central oxygen

at least 1/ available

16 Defibrillator at least 1

17 ECG machine at least 1

18 Pulse oximeter at least 1

19 Nebulizer at least 1

20 Cardiac monitor at least 1

21 Torch light at least 1

Total score

Total percentage= Total score/21 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.9b Medicines and Supplies for Hemodialysis

S.No Medicines and supplies Required No Score

1 Diazepam Injection 5

2 Frusemide Injection 5

3 Ondansetron Injection 5

4 Ranitidine Injection 5

5 Noradrenaline Injection 5

6 Phenytoin Injection 5

7 Diclofenac sodium Injection 5

121

8 Deriphylline Injection 5

10 Hydrocortisone Injection 5

11 Atropine Injection 5

12 Adrenaline Injection 5

13 Potassium Chloride (KCL) Injection 5

14 Pheniramine Injection 5

15 Sterile Water 5

16 Soda bicarbonate Injection 5

17 Dopamine Injection 5

18 Calcium Gluconate Injection 5

19 Dextrose 25 %/ 50% Injection 5each

21 Tranxemic Acetate Injection 5

22 Protamine Sulphate Injection 5

23 Vitamin K Injection 5

24 Tramadol Injection 5

25 Hyoscine Butylbromide Injection 5

26 Aspirin Tablet 1 strip

27 Clopilet Tablet 1 strip

28 Isodril Tablet 1 stirp

29 Nefedipin 5 mg/10mg Cap 1 strip each

30 Injection Heparin as per need

Dialysis Consumables

31 Adhesive Tape as per need

32 Leukoband as per need

33 Paper Tape as per need

34 Betadine as per need

35 Spirit as per need

122

36 Dialyzer as per need

37 A/V Tubing as per need

38 Fistula Needle as per need

39 I/V Set as per need

40 I/V Cannula different size as per need

41 Transducer as least 2

42 Sub clavien Catheter at least 2

43 Femoral Catheter at least2

44 Guide wire at least 2

45 Normal Saline 1000ml as per need

46 Normal Saline 500ml at least 5

47 Disposable Syringe 20ml as least 5

48 Disposable Syringe 10ml at least 5

49 Disposable Syringe 5ml at least 5

50 Rubber Sheet as per need

Total Score

Total percentage= Total Score/50 x100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


123

Area Code

Verification

Intensive Care Services

2.10

Intensive care unit (ICU) 2.10.1


Maximum Score

2.10.1 ICU service for both inpatient and referral cases

2.10.1.1 ICU service is available for inpatients and referral critical cases round the clock 1

2.10.1.2 Minimum number of ICU beds is 5% of total hospital beds 1

2.10.1.3 One ICU set up has at least 5 ICU beds 1Adequate physical facilities

2.10.1.2 Strategic location of ICU in hospital

2.10.1.2.1ICU must have easy access and connectivity with operation theatre complex, emergency department, radio-imaging and clinical lab.

1

2.10.1.2.2ICU must have a single entry and exit point to allow free access to heavy duty machines like mobile x-ray, bed and trolleys on wheels

1

2.10.1.2.3 There must be at least two barriers to the entry of ICU 1

2.10.1.2.3 Separate designated space in ICU for

2.10.1.2.4 Family waiting area with chairs at least one for each ICU bed 1

2.10.1.2.5 Counselling room with working desk and chairs 1

2.10.1.2.6Central Nursing Station with working desk, centrally connected monitors display of each bed and at least three chairs

1

2.10.1.2.7 Nurse's Room with tea room facility and reference books in shelves 1

2.10.1.2.7 Doctor's Room with tea room facility and reference books in shelves 1

2.10.1.2.8 Utility Room with separate dirty and clean linen storage 1

2.10.1.2.9Changing Room (Separate for male and female) with adequate number of lockers for staffs’ belongings

1

2.10.1.2.10 Wash room (Separate for male and female with at least one universal) 1

2.10.11Proper bed area allocated for each bed with supplies (See Annex 2.10.1a Proper Bed Area for ICU At the end of the standard)

3

2.10.1.2.12 Lighting: Access to natural light 1

2.10.1.2.13ICU must have air conditioner to maintain the temperature, humidity and air flow and closed to outer environment

1

2.10.1.2.14 High illumination spot lighting for procedures, like putting central lines etc. 1

2.10.1.2.15 There must be proper fire extinguishing machines. 1

124

2.10.1.3 Staffing

2.10.1.3.1ICU has staffing as per annex . (See Annex 2.10.1b Staffing of Intensive care services At the end of the standard)

3

2.10.1.3.2

There must be one ICU in-charge (Nursing officer) with minimum of bachelor in critical care or trained in critical care for overall management of ICU

1

2.10.1.4 Equipment and instruments available and functioning

2.10.1.4

ICU has adequate equipment and instruments to function adequately (See Annex 2.10.1c Equipment and Instrument for intensive care services At the end of the standard)

3

2.10.1.5 Duty rosters 2.10.1.5

Duty roster for 24 hours is prepared and placed in visible area for all ICU staffs including doctors and nurses

1

2.10.1.6 ICU protocol in place and followed

2.10.1.6.1

ICU must practice given protocols on all given clinical conditions with all staffs in ICU trained in Basic Life Support, Advance Life Support, Critical Care Support, Mechanical Ventilation, Infection prevention

1

2.10.1.6.2 All ICUs must be designed to handle disasters both within ICU and outside the ICU 1


2.10.1.7.1

Separate sheet tailored for ICU set up is used for continuous monitoring of the patients and e-recording done in standard software approved by MoHP

1

2.10.1.7.2

Handover and takeover of the patients from ER or other wards is done with patient being received in ICU accompanied by respective ward at least staff nurse or paramedics

1

2.10.1.7.3Complications, morbidity and mortality are recorded, reported and proceeded for clinical audit on regular basis (at least weekly)

1


2.10.1.8.1 10% of beds (1 to 2) should be separated as isolation beds in each ICU 1

2.10.1.8.2Hand Hygiene protocol developed and followed between each ICU bed with alcohol hand rubs or sanitizer

1

2.10.1.8.3Separate space designated for scrub station with running water and liquid soap, elbow lever and hand drier available and functional

1

2.10.1.8.4 Waste disposal as per HCWM guideline 2014 (MoHP) 1

2.10.1.8.5 Gown and slippers for doctors, nurses, visitors 1


Standard 2.10.1Total obtained score 40

Total percentage= Total obtained score/40 x 100

125

Neonatal Intensive care unit

2.10.2 Verification


Maximum Score

2.10.2.1 NICU service for both inpatient and referral cases

2.10.2.1.1 NICU service is available for inpatients and referral critical cases round the clock 1

2.10.2.1.2 Minimum number of NICU beds is 5% of total hospital beds 1

2.10.2.1.3 One NICU set up has at least 5 NICU beds 1

2.10.2.2 Adequate physical facilities

2.10.2.2.1NICU must have easy access and connectivity with operation theatre complex, emergency department, radio-imaging and clinical lab.

1

2.10.2.2.2NICU must have a single entry and exit point to allow free access to heavy duty machines like mobile x-ray, bed and trolleys on wheels

1

2.10.2.2.3 There must be at least two barriers to the entry of NICU 1

2.10.2.2.4 Separate designated space in NICU for

2.10.2.2.4.1 Family waiting area with chairs at least one for each NICU bed 1

2.10.2.2.4.2 Counselling room with working desk and chairs 1

2.10.2.2.4.3Breast feeding room with comfortable chair and air conditioning for mother to feed or express breast milk

1

2.10.2.2.4.4

Central Nursing Station with working desk, centrally connected monitors display of each bed and at least three chairs

1

2.10.2.2.4.5 Nurse's Room with tea room facility and reference books in shelves 1

2.10.2.2.4.6 Doctor's Room with tea room facility and reference books in shelves 1

2.10.2.2.4.7 Utility Room with separate dirty and clean linen storage 1

2.10.2.2.4.8Changing Room (Separate for male and female) with adequate number of lockers for staffs’ belongings

1

2.10.2.2.4.9 Wash room (Separate for male and female with at least one universal) 1

2.10.2.2.4.10 Lighting: Access to natural light 1

2.10.2.2.4.11NICU must have air conditioner to maintain the temperature, humidity and air flow and closed to outer environment

1

2.10.2.2.4.12 High illumination spot lighting for procedures, like putting central lines etc. 1

2.10.2.2.4.13 There must be proper fire extinguishing machines. 1

2.10.2.3 Staffing 2.10.2.3

NICU has staffing as per annex (See Annex 2.10.1b Staffing of Intensive care services At the end of this standard)

3

126


2.10.2.4

ICU has adequate equipment and instruments to function adequately (See Annex 2.10.1c Equipment and Instrument for intensive care services At the end of this standard)

3

2.10.2.5 Duty rosters 2.10.2.5

Duty roster for 24 hours is prepared and placed in visible area for all NICU staffs including doctors and nurses

1

2.10.2.6 NICU protocol in place and followed

2.10.2.6.1

NICU must practice given protocols on all given clinical conditions with all staffs in NICU trained in Basic Life Support, Pediatric Advance Life Support, Critical Care Support, Mechanical Ventilation, Infection prevention, Tube feeding, Incubators, Warmer, Phototherapy

1

2.10.2.6.2All NICUs must be designed to handle disasters both within NICU and outside the NICU

1


2.10.2.7.1

Separate sheet tailored for NICU set up is used for continuous monitoring of the patients and e-recording done in standard software approved by MoHP

1

2.10.2.7.2

Handover and takeover of the patients from ER or other wards is done with patient being received in NICU accompanied by respective ward at least staff nurse or paramedics

1


1


2.10.2.8.1 10% of beds (1 to 2) should be separated as isolation beds in each NICU 1

2.10.2.8.2Hand Hygiene protocol developed and followed between each NICU bed with alcohol hand rubs or sanitizer

1


1

2.10.2.8.4 Every neonate must be properly cleaned /wiped everyday by using approved solution. 1

2.10.2.8.5Use of personal protective equipment while caring each neonate to prevent cross infection.

1






127

Pediatric Intensive care unit

2.10.3 Verification


Maximum Score

2.10.3.1 PICU service for both inpatient and referral cases

2.10.3.1.1 PICU service is available for inpatients and referral critical cases round the clock 1

2.10.3.1.2 One PICU set up has at least 5 PICU beds 1


2.10.3.2.1PICU must have easy access and connectivity with operation theatre complex, emergency department, radio-imaging and clinical lab.

1

2.10.3.2.2PICU must have a single entry and exit point to allow free access to heavy duty machines like mobile x-ray, bed and trolleys on wheels

1

2.10.3.2.3 There must be at least two barriers to the entry of PICU 1

2.10.3.2.4 Separate designated space in PICU for

2.10.3.2.5 Family waiting area with chairs at least one for each PICU bed 1

2.10.3.2.6 Counselling room with working desk and chairs 1

2.10.3.2.7Central Nursing Station with working desk, centrally connected monitors display of each bed and at least three chairs

1

2.10.3.2.8 Nurse's Room with tea room facility and reference books in shelves 1

2.10.3.2.9 Doctor's Room with tea room facility and reference books in shelves 1

2.10.3.2.10 Utility Room with separate dirty and clean linen storage 1

2.10.3.2.11Changing Room (Separate for male and female) with adequate number of lockers for staffs’ belongings

1

2.10.3.2.12 Wash room (Separate for male and female with at least one universal) 1

2.10.3.2.13 Proper bed area allocated for each bed with supplies 1

2.10.3.2.14 Lighting: Access to natural light 1

2.10.3.2.15 PICU must have air conditioner to maintain the temperature, humidity and air flow and closed to outer environment

1

2.10.3.2.16 High illumination spot lighting for procedures, like putting central lines etc. 1

2.10.3.2.17 There must be proper fire extinguishing machines. 1

2.10.3.3 Staffing 2.10.3.3

PICU has staffing as per annex. (See Annex 2.10.1b Staffing of Intensive care services At the end of this standard)

3

128


2.10.3.4

PICU has adequate equipment and instruments to function adequately (See Annex 2.10.1c Equipment and Instrument for intensive care services At the end of this standard)

3

2.10.3.5 Duty rosters 2.10.3.5

Duty roster for 24 hours is prepared and placed in visible area for all PICU staffs including doctors and nurses

1

2.10.3.6 PICU protocol in place and followed

2.10.3.6.1

PICU must practice given protocols on all given clinical conditions with all staffs in PICU trained in Basic Life Support, Advance Life Support, Critical Care Support, Mechanical Ventilation, Infection prevention

1

2.10.3.6.2 All PICUs must be designed to handle disasters both within PICU and outside the PICU 1


2.10.3.7.1

Separate sheet tailored for PICU set up is used for continuous monitoring of the patients and e-recording done in standard software approved by MoHP

1

2.10.3.7.2

Handover and takeover of the patients from ER or other wards is done with patient being received in PICU accompanied by respective ward at least staff nurse or paramedics

1


1


2.10.3.8.1 10% of beds (1 to 2) should be separated as isolation beds in each PICU 1

2.10.3.8.2Hand hygiene protocol developed and followed between each PICU bed with alcohol hand rubs or sanitizer

1


1

2.10.3.8.4 Every neonate must be properly cleaned /wiped everyday by using approved solution. 1

2.10.3.8.5 Use of personal protective equipment while caring each neonate to prevent cross infection. 1






129

Annex 2.10.1a Proper Bed Area for ICU

S.No. Appropriate bed space and supplies Score

1. 100 sq. ft per patient care area

2. Bed length: 7 ft; Bed width: 3.5 ft

3. The head end of the bed must be kept at least 2 ft from the wall to have adequate access for endotracheal intubation, resuscitation, and central venous catherization

4. The foot end of the bed must be kept at least 3 ft from the corridor or wall.

5. Space between the two adjacent beds: 5 ft

6. Wall or ceiling mounted pendants to reduce the space requirements and to provide hindrance free and smooth accessibility at the head end of the bed.

7. Utilities per bed in the pendant: 2 oxygen outlets with flow meters, 2 vaccuum, 8 universal electric outlets distributed on both sides of the bed.

Total Score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3

Score for Standard2.10.1.11

130

Annex 2.10.1b Staffing for Intensive Care Services

S.No. Staffing of ICU Required Number ICU NICU PICU

1. ICU Coordinator with at least MD Anesthesiology (dedicates 50%of professional time in ICU)

1

2. NICU/ PICU Coordinator with at least MD Pediatrics (dedicates 50%of professional time in NICU/PICU)

3. Admitting consultant on duty 1

4. One trained medical officer for each 5 bed 1 per shift

5.

Nurse in-charge with 5 years’ experience in ICU with at least Nursing officer (Bachelors’ degree in critical care/ critical care trained)

1

6. Nurse: patient ventilated and multi-organ failure patients 1:1

7. Nurse: Patients ventilated or multi-organ failure patients 2:3

8. Nurse: Patients less seriously sick patients who do not require above modalities. 1:2

9. Infection Prevention trained office assistants

1in each shift for 5 bedded ICU

10. Security staffs 2 in each shift

11. Biomedical technician/engineer on duty At least one

Total Score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3




131

Annex 2.10.1c Equipment and Instrument for Intensive Care Services

S.N. Equipment, Instrument and Supplies for ICU

Required number

ScoreICU NICU PICU

1.

ICU bed (With mattress, two iv stands and all position possible: height adjustment, back section and leg section adjustment, tredelenberg and reverse trendelenberg position)

one per bed

2. Bedside Patient monitor (Modular - ECG, SPO2, NIBP, RR, Temp Probes with trays) upgradable to invaseive BP

one per bed

3. Bedside Patient monitor (Modular - ECG, SPO2, NIBP, 2 Invasive BP, RR, Temp Probes with trays)

two out of five monitors

4.

ICU Ventilator (With paediatric and adult provisions, graphics and Non- Invasive Modes, Humidifier, inbuilt nebulisation, turbine/air-compressor)

one per bed

5. BiPAP Machine two for five beds

6. Defibrillator (manual and automated with transcutaneous pacing facility) One

7. Syringe pumps 4 per bed

8. Infusion pumps 1 per bed

9. Over Bed Table 1 per bed

10. Bedside Cabinet 1 per bed

11. Handheld Pulse oximeter 2

12. ABG Machine 1

13. Hemodialysis Machine 1

14. Intermittent Leg Compressing Device to prevent DVT 1 per bed

15. Air mattress 1 per bed

16. Crash/Resuscitation trolley 1

17. Glucometer 2

18. Portable X-ray machine 1

19. Clinical Lab facility with lactate value, culture and sensitivity Available

20. Warming devices: blanket, blower As per need

Total Score

Total percentage= Total Score/ 20x 100

132


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3




Area Code

Verification

Diagnostics and laboratory

2.11

Laboratory 2.11.1.1


Maximum Score

2.11.1.1.1Time for patients

2.11.1.1.1.1Laboratory is open from 10 AM to 3 PM for routine services and separate emergency lab service available round the clock

1

2.11.1.1.1.2Basic investigations are available (See Annex 2.11.1a List of investigations for Laboratory At the end of this standard)

3

2.11.1.1.2 Staffing

2.11.1.1.2.1

Laboratory team is lead by pathologist (at least 2 - one for hematology, histocytopathology and biochemistry, one for microbiology)

1

2.11.1.1.2.2At least 7 staffs - 2 technologist, 2 technicians 1 assistant and 2 helpers are available for routine lab

1

2.11.1.1.2.3 At least 3 staffs (1 Technician, 1 Assistant and 1 Helper) in each shift in emergency lab 1

2.11.1.1.2.4 On call biomedical engineer available for maintenance of lab equipment 1

133

2.11.1.1.3 Instruments and equipment

2.11.1.1.3.1

Instruments and equipment to carry out all parameters of tests are available and functioning(See Annex 2.11.1.1b Equipment and Instrument for Lab At the end of this standard)

3

2.11.1.1.3.2 Instrument are maintained and calibrated as per manufacturer instructions 1

2.11.1.3.3 Quality control sera and standards are run regularly and record kept 1

2.11.1.1.4 Physical facilities

2.11.1.1.4.1

Separate space with working desk and chair designated for specific laboratory procedures like- hematology, biochemistry, microbiology, serology, histopathology and cytology

1

2.11.1.1.4.2 Light and ventilation are adequately maintained. 1

2.11.1.1.4.3 Designated area well labelled for reception of sample and dispatch of reports 1

2.11.1.1.4.4 Power back up is available for the lab for preservation of sample and regents 1

2.11.1.1.5 Duty rosters 2.11.1.1.5 Duty rosters of lab are developed regularly


2.11.1.1.6 Facilities for patients

2.11.1.1.6.1Waiting space with sitting arrangement is available for at least 15 persons in waiting lobby.

1

2.11.1.1.6.2 At least one each male, female and universal toilet for patients using laboratory services 1

2.11.1.1.6.3 Safe drinking water is available in the waiting lobby throughout the day. 1

2.11.1.1.7 Recording and reporting

2.11.1.1.7.1Sample is adequately recorded with requisition form with detail information of patients

1

2.11.1.1.7.2Standard reporting sheets are being used and all reports are recorded in a standard register (HMIS 9.4).

1

2.11.1.1.7.3Copy of computerized report is kept safe (hard and soft copies) for future use till 6 months and report is available to patient

1

2.11.1.1.7.4Report have adequate information of patient and checked by designated person before release

1

2.11.1.1.8 Supplies storage and stock

2.11.1.1.8.1 At least three months buffer stock of laboratory supplies is available. 1

2.11.1.1.8.2 Reagents are stored at appropriate temperature in store and lab 1

2.11.1.1.9 Blood Bank within hospital premises

2.11.1.1.9

Blood bank should be available inside hospital premises either owned by hospital or Nepal Red Cross Society(If hospital has its own blood bank refer to standard 2.11.1.2)

1

134

2.11.1.1.10 Infection prevention

2.11.1.1.10.1 Closed vacuum system is used for sample collection 1

2.11.1.1.10.2 Biohazard signs and symbols are used at appropriate places visibly 1

2.11.1.1.10.3 All staffs know how to respond in case of spillage and other incidents 1

2.11.1.1.10.4 Masks and gloves are available 1

2.11.1.1.10.5

There are colored bins for waste segregation based on HCWM guideline 2014 (MoHP) and infectious waste is sterilized using autoclave before disposal

1

2.11.1.1.10.6 Hand-washing facility with running water and soap is available for practitioners 1

2.11.1.1.10.7 Needle cutter is used 1

2.11.1.1.10.8 Chlorine solution and bleach is available and utilized for decontamination 1

Standard 2.11.1.1Total Obtained Score 36


Annex 2.11.1.1a List of Investigations for Laboratory

SN Test Routine

Hematology

1. Hb

2. Total Leucocyte count

3. Differential leucocyte count

4. ESR

5. Blood grouping for non- transfusion

6. Blood grouping for transfusion

7. Bleeding time

8. PT

9. APTT

10. Platelet count

11. MCV

12. MCH

13. MCHC

135

14. Hematocrit (PCV)

15. Malaria RDT or microscopy

16. Absolute count

17. Reticulocyte

18. Peripheral smear examination

19. Sickling test

Chemistry and Endocrinology

20. Blood Sugar

21. Urea

22. Creatinine

23. Billirubin total

24. Billirubin direct

25. Serum Uric acid

26. Total Protein

27. Serum albumin

28. SGOT

29. SGPT

30. Alkaline phosphatase

31. Triglyceride

32. Total Cholesterol

33. HDL

34. LDL

35. Serum sodium

36. Serum potassium

37. Beta hCG

38. HbA1c

39. Urine microalbumin

40. Urine albumin creatinine ratio

41. Total CK

42. CK-MB

43. Troponin T/I

136

44. Amylase

45. Lipase

46. Thyroid function test

47. Beta hCG

Microbiology

48. Sputum AFB

49. KOH mount

50. Routine bacteriology culture (blood, urine, pus, body fluid, swab)

51. Antibiotic susceptibility

52. Gram stain

Serology

53. RPR

54. Widal

55. ASO

56. RA factor

57. CRP

58. rK39 (kit)

59. Montoux test

60. TPHA (rapid)

61. HbsAg (rapid)/ CLIA/ ELISA

62. HCV(rapid)

63. HIV(rapid)

Miscellaneous

64. Urine routine and microscopy

65. Urine Pregnancy Test

66. Stool routine and microscopy

67. Stool for occult blood

68. Stool for reducing substance

69. Urine ketone bodies

70. CSF and body fluid examination (sugar, protein, total and differential count, malignant cells)

137

71. Semen analysis (total count and motility)

72. Pap smear examination

73. Sputum cytology

74. Body fluid cytology

75. Biopsy service (Histopathology services)

76. Fine needle aspiration cytology

77. Bone marrow aspiration and biopsy

Total Score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.11.1.1b Equipment and Instrument for Laboratory

S.N. Name of Instruments Required Quantity Score

1. Microscope 3

2. Fully automated biochemistry analyser 1

3. Fully automated hematology analyser 1

4. HBA1c measuring instrument ( semiautomated/ automated) 1

5. ELISA/CLIA/ECL 1

6. Incubator 1

7. Biosafety cabinet ( for microbiology) 1

8. Chemical Balance 1

138

9. Electrolyte Analyzer 1

10. Hot air Oven 1

11. Refrigerator 1-2

12. Centrifuge 1-2

13. Counting Chamber 1-2

14. DLC counter 1-2

15. Tissue Processor 1

16. Microtome 1

17. Pipettes, Glassware/kits As per need

18. Computer with printer 1

19. Water Bath 1

20. Tissue flotation bath 1

21. Disposable test tubes As per need

22. Different Closed Vacuum set (for sample)- hematology, biochemistry

As per need

23. Autoclave for waste disposal (250 liter, pre-vacuum with horizontal outlet)

1

Total Score

Total percentage = Total Score/ 23 x 100


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


139

Area CodeVerification (*Applicable if hospital has its own blood bank)

Blood Bank* 2.11.1.2


Maximum Score

2.11.1.2.1 Time for patients 2.11.1.2.1 Blood bank is open / facility is available round

the clock 1

2 . 1 1 . 1 . 2 . 2 Staffing 2.11.1.2.2

Adequate numbers of trained healthcare workers are available in blood bank (at least 2 blood bank staffs to cover shifts including ER)

1

2.11.1.2.3 Physical facilities

2.11.1.2.3.1Adequate rooms and space for the staffs and patients are available (area of more than 10 meter squares)

1

2.11.1.2.3.2 Light and ventilation are adequately maintained. 1

2.11.1.2.3.3

The required furniture and supplies are available (See Annex 2.11.1.2a Blood Bank Furniture and Supplies At the end of the standard)

3

2.11.1.2.3.4

Thermometers are attached to all equipment requiring temperature control and temperatures are recorded daily or temperature sensor based equipment

1

2 . 1 1 . 1 . 2 . 4 I n s t r u m e n t s and equipment

2.11.1.2.4

Instruments and equipment are calibrated, available and functioning with record of smear kept (See Annex 2.11.1.2b Equipment and Instrument for Blood Bank At the end of the standard)

3

2.11.1.2.5 Duty rosters 2.11.1.2.5 Duty rosters of lab are developed regularly and

available in appropriate location. 1

2.11.1.2.6 Facilities for patients

2.11.1.2.6.1Comfortable waiting space with sitting arrangement is available for at least 10 persons in waiting lobby.

1

2.11.1.2.6.2 Safe drinking water is available in the waiting lobby throughout the day. 1

2.11.1.2.7 Recording and reporting

2.11.1.2.7.1 Sample is adequately recorded with requisition form with detail information of patients 1

2.11.1.2.7.2

Standard reporting sheets are being used and all reports are recorded in a standard register or NBBTS software and computerized bill available to patients

1

2.11.1.2.7.3Report have adequate information of patient and checked by designated person before release

1

2.11.1.2.7.3 BTSC submits regular reports to NPHL/NBBTS of provided proficiency panels related to TTIs 1

2.11.1.2.8 Supplies storage and stock

2.11.1.2.8.1 At least three months buffer stock of laboratory supplies is available. 1

2.11.1.2.8.2Blood bags, transfusion sets, blood and blood components, reagents are stored at appropriate temperature in store and lab

1

140

2.11.1.2.9 Infection prevention

2.11.1.2.9.1 Biohazard signs and symbols are used at appropriate places 1

2.11.1.2.9.2 All staffs know how to respond in case of spillage and other incidents 1

2.11.1.2.9.3 Masks and gloves are available 1

2.11.1.2.9.4 Bio-waste disposal is done based on HCWM guideline 2014 (MoHP) 1

2.11.1.2.9.5 Hand-washing facility with running water and soap is available for practitioners 1

2.11.1.2.9.6 Needle cutter is used 1

2.11.1.2.9.7 Chlorine solution and bleach is available and utilized for decontamination 1

Standard 2.11.1.2Total Obtained Score 27

Total Percentage (Total Obtained Score/27x100)

Annex 2.11.1.2a Blood Bank Furniture and Supplies

S.N. Furniture and supplies Required Quantity Score

1. Working desk with two chairs 1 set

2. Patient chair for blood collection 1

3. Blood bag single and/or component As per need

4. BP cuff 1

5. Stethoscope 1

6. Weighing machine (for patient and for blood) As per need

7. Band aid, cotton and spirit As per need

8. Needle cutter as per need

9. Reagents Kits for ABO/Rh serology/cross-matching requirement as per need

10. Glass ware for blood grouping (ABO/Rh) as per need

Total score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3

Score 2.11.1.2.3.1

141

Annex 2.11.1.2b Equipment and Instrument for Blood Bank

S.N. Name of Instruments Required Quantity Score

1. Blood bank refrigerator 2 to 4٥ C 2

2. Ordinary centrifuge 3

3. Deep freezer (-20°C to -30°C) 1

4. Deep freezer (-80°C) 1

5. Platelet Shaker 1

6. Autoclave 1

7. Computer with printer 1

8. Gamma radiation chamber 1 (optional*)

9. Microscope 1

10. Auto pipettes (20, 50, 100 μl) 2 each

11. Incubator 2

12. Water Bath 3

13. Hot Air Oven 2

14. Generator 60 KVA as per need

Total score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3

Score 2.11.1.2.3.3

142


X-ray 2.11.2


Maximum Score

2.11.2.1 Time for patients

2.11.2.1.1 X-ray service is open from 10 AM to 3 PM 1

2.11.2.1.2 Emergency x-ray service is available round the clock 1

2.11.2.2 Staffing 2.11.2.2

Adequate numbers of trained healthcare workers are available in x-ray (at least 2 staffs to cover shifts including ER) with on duty radiologist

1

2.11.2.3 Patient counseling 2.11.2.3 Counseling is provided to patients about

radiation hazard, site and position for x-ray 1

2.11.2.4 Information education and communication materials for patients

2.11.2.4Radiation sign, appropriate Radiation awareness posters, leaflets are available in the department and OPD waiting area.

1

2.11.2.5 Instruments and equipment

2.11.2.5General X ray unit (with minimum 125KV and 300ma X-ray machine) with floatation table top and vertical bucky

1

2.11.2.6 Mobile X ray unit 1 for bed side radiography for inpatient is available and functioning. 1

2.11.2.7 Complete CR system with CR cassette at least 5 of 14 x 17 inch and 3 of 10x12inch. 1


2.11.2.8.1X ray room of at least 4x4sqm with wall of at least 23cm of brick or 6cm RCC or 2mm lead equivalent.

1


2.11.2.8.3

The required furniture and supplies including radiation protective measures for patients, visitors and staffs are available including lead gown

1

2.11.2.9 Duty rosters 2.11.2.9 Duty rosters of X-ray are developed regularly



2.11.2.10Waiting space with sitting arrangement is available for at least 5 persons in waiting lobby.

1


2.11.2.11.1X-ray is adequately recorded as per requisition form with detail information of patients, date of x-ray and site and view

1

2.11.2.11.2Report have adequate information of patient and checked by designated person before release

1

2.11.2.12 Information to patients

2.11.2.12 Biohazard signs and symbols are used at appropriate places 1

143


2.11.2.12.1 Radiological waste is disposed based on HCWM guideline 2014 (MoHP) 1

2.11.2.12.2 Hand-washing facility with running water and soap is available for practitioners 1


2.11.2.12.4 Chlorine solution and bleach is available and utilized for decontamination 1

Standard 2.11.2Total Obtained Score 20Total Percentage (Total Obtained Score/ 20 x100)

Area CodeVerificationUltrasonography

(USG) 2.11.3


Maximum Score

2.11.3.1 Time for patients 2.11.3.1

USG is open from 10 AM to 3 PM for obstetrics, abdominal, pelvic and superficial structure like testis, thyroid

1

2.11.3.2 Staffing 2.11.3.2USG trained medical practitioner and mid-level health worker (preferably female) in each USG room

1

2.11.3.3 Patient counseling 2.11.3.3 Counseling is provided to patients about site

and indication of USG 1

2.11.3.4 Maintaining patients’ privacy

2.11.3.4


1

2.11.3.5 Instruments and equipment

2.11.3.5

USG machine (advanced) with different probes, computer and printer with USG papers , gel and wipes is available and functional

1


2.11.3.6.1 Adequate space for practitioner and patient for USG with working table and examination bed one per each USG machine

1

2.11.3.6.2 Proper light and ventilation maintained. 12.11.3.7 Facilities for patients

2.11.3.7Comfortable waiting space with sitting arrangement is available for at least 15 persons in waiting lobby.

1


2.11.3.8.1USG is adequately recorded as per requisition form with detail information of patients, date of USG

1

2.11.3.8.2

Report have adequate information of patient, information of area of examination and radiological opinion, further referral and checked by designated person before release

1






144

Area CodeVerificationElectrocardiogram

(ECG) 2.11.4


Maximum Score

2.11.4.1 Service available 2.11.4.1 ECG service is available for patients in

OPD, Emergency and Indoor 1

2.11.4.2 Space 2.11.4.2 Separate space is dedicated for ECG Service 1


procedure and indication of ECG 1

2.11.4.4 Maintaining patient privacy 2.11.4.4


1

2.11.4.5 Instruments, equipment and supplies

2.11.4.5Functional ECG machine (12 lead with power back up), paper, gel, wipes and hand sanitizer are available in ECG trolley

1


2.11.4.6.1ECG is adequately recorded as per requisition form with detail information of patients, date of ECG

1

2.11.4.6.2

Reporting folder of ECG should have adequate information of patient, including analysis of 12 lead ECG with final impression of ECG diagnosis done by designated person before release

1


2.11.4.7.1 Hand-washing facility with running water and liquid soap is available for practitioners 1




Echocardiogram (Echo) 2.11.6 Verification


Maximum Score

2.11.6.1 Adequate time for patients

2.11.6.1.1 Echo service is available from 10 AM to 3 PM 1

2.11.6.1.2 Emergency Echo is available round the clock (optional)

2.11.6.2 Adequate health workers 2.11.6.2

Cardiologist is available for Echo service with at least one mid-level health worker assigned in Echo

1


procedure and indication of Echo 1

145

2.11.6.4 Adequate instruments, equipment and supplies

2.11.6.4

Functional Echo machine (2D, M-mode, color doppler), computer and printer with Echo papers, gel, wipes and hand sanitizer are available

1


2.11.6.5.1 Separate space allocated for Echo with changing room and patients’ gown 1

2.11.6.5.2 Proper light and ventilation are adequately maintained 1

2.11.6.5.3Echo examination bed with mattress and bed cover and pillow with curtains for privacy of patients

1


2.11.6.6.1Echo is adequately recorded as per requisition form with detail information of patients, date of echo and echo diagnosis

1

2.11.6.6.2Report have adequate information of patient and checked by designated person before release

1



2.11.6.7.2 Chlorine solution and bleach is available and utilized 1


Treadmill (TMT) 2.11.7 Verification


Maximum Score


2.11.7.1 Treadmill (TMT) service is available from 10 AM to 3 PM 1

2.11.7.2 Adequate health workers

2.11.7.2At least one trained medical officer / cardiologist and one mid-level health worker is allocated for TMT service

1

2.11.7.3 Patient counseling 2.11.7.3

Counseling is provided to patients about procedure, indication and anticipated complication during TMT as well as to modify the routine cardiac medications as per TMT protocol.

1

2.11.7.4 Adequate instruments, equipment, medicines and supplies

2.11.7.4.1Functional TMT machine with display monitor and printer, paper, ECG lead, wipes and hand sanitizer are available

1

2.11.7.4.2

Emergency trolley with emergency drugs and supplies readily available (See Annex 2.11.7a Emergency Trolley TMT At the end of this standard)

3

2.11.7.4.3 Synchronized Defibrillator is available and functional in TMT room 1

2.11.7.4.4 Injection Dobutamine available for Stress TMT 1

146


2.11.7.5.1 Separate room allocated for TMT with changing room, gown for patient and locker for patients’ belongings

1



2.11.7.6.1TMT is adequately recorded as per requisition form with detail information of patients, date of TMT

1

2.11.7.6.2

TMT report should have adequate information of patient, achievement of target heart rate, blood pressure response with exercise, any ECG changes, any complication observed during exercise and recovery period and checked by designated person before release

1


2.11.7.7.1 Hand-washing facility with running water and liquid soap is available for practitioners 1



Total Percentage = Total Obtained Score/ 15x100

Annex 2.11.7a Emergency Trolley TMT






5. Xylocaine Gel 2




9. Morphine Injection / Injection Pethidine 2


11. Phenaramine Injection 4



147







20. Glyceryltrinitrate Injection 1





25. Dextrose 25% / 50% Injection 2 each


27. IV Canula ( 18, 20, 22, 24 Gz) 2 each




31. Needle 18-25 As per need


Total Score

Total Percentage (Total Score/ 32x100)


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


148

Endoscopy 2.11.8 Verification


Maximum Score


2.11.8.1. 1 Endoscopy service is available from 10 AM to 3 PM 1

2.11.8.1. 2 Emergency endoscopy is available round the clock 1


2.11.8.2.1

Separate room designated for endoscopy with adjustable patient bed, head adjustable recovery bed, working chair for practitioner and working table with at least two chairs

1

2.11.8.2.2 Scopes hanging area for storage. (covered cupboards/ shelves) 1

2.11.8.2.3 Proper light and ventilation maintained 1

2 . 1 1 . 8 . 3 A d e q u a t e staffing

2.11.8.3.1

Physician/ surgeons having endoscopic training or Gastroenterologist or hepatologist or gastrointestinal surgeons with at least 2 Trained endoscopic nurse/paramedic designated for endoscopy room

1

2.11.8.3.2One mid-level trained health worker for record keeping, booking, and report dispatch , counselling before procedure

1


Counseling is provided to patients about procedure and indication of Endoscopy with possible complications

1

2.11.8.5 Adequate instruments, equipment, medicines and supplies

2.11.8.5.1

Functional Video-endoscopy machine with attachable gastroscope and colonscope; bronchoscope (optional) with cardiac monitor available

1

2.11.8.5.2 Portable Diathermy machine with cautery wires for endoscopic procedure standard. 1

2.11.8.5.3

Emergency trolley with emergency drugs and supplies readily available (See Annex 2.11.8a Emergency Trolley Endoscopy At the end of this standard)

3


2.11.8.6.1Recording and printing system (computer, color printer with capture card and reporting software for UGI endoscopy, colonoscopy)

1

2.11.8.6.2

Endoscopy report is adequately recorded as per requisition form with detail information of patients, date of endoscopy and pictures attached

1

2.11.8.6.3

Report have adequate information of patient, visibly printed pictures captured during endoscopy, endoscopic observation of structure, diagnosis and relevant endoscopic procedures performed and complications observed if any and checked by designated person before release

1

149



2.11.8.7.2 Personal protective equipment including utility gloves and boots available and used 1

2.11.8.7.3 Separate tubs for washing, disinfection and final cleaning of the scopes available and used 1

2.11.8.7.4Disinfectant solution (gluteraldehyde) and Citezyme solution for enzymatic cleaning of scopes available and used

1

2.11.8.7.5 Chlorine solution and bleach is available and utilized for decontamination (*not for scopes) 1


Total Percentage (Total Obatined Score/ 21 x100)

Annex 2.11.8a Emergency Trolley Endoscopy






5. Xylocaine Gel 2




9. Morphine Injection / Pethidine Injection 2


11. Pheramine Injection 4




150






20. Glyceryltrinitrate injection 1





25. Dextrose 25%/50% ampoule 2


27. IV Canula (16, 18, 20, 22, 24, 26 Gz) 2 each




31. Sodium chloride-15%w/v and Glycerin-15% w/v (for enema) As per need

Total Score

Total Percentage (Total Score/ 31x100)


Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


151

Audiometry 2.11.9 Verification


Maximum Score


2.11.9.1 Audiometry service is available from 10 AM to 3 PM 1

2.11.9.2 Adequate health workers

2.11.9.2 ENT specialist is available for performing audiometry 1


Counseling is provided to patients about procedure and indication of audiometry and explain patient about the examination booth

1

2.11.9.4 Adequate instruments, equipment and supplies

2.11.9.4

Functional Audiometer with power supply and response switch, headphones, earphones with audiometric calibration stand and 500g weight and audiometer patch cords available

1


2.11.9.5.1

Separate room allocated for audiometry with a special booth made of acoustic medium is available with custom-built triangular table with the audiometer on top and the computer tower beneath and an area outside booth for working area for technologist

1

2.11.9.5.2Sound dampening materials on the interior walls of the exam room and a rubber seal on the hallway door

1



2.11.9.6.1 Computer available for recording and reporting of the test results 1

2.11.9.6.2Audiometry is adequately recorded as per requisition form with detail information of patients and diagnosis

1

2.11.9.6.3

Report have adequate information of patient, results of audiometry and advices for further hearing related treatment and checked by designated person before release

1



2.11.9.7.2 Chlorine solution and bleach is available and utilized 1


Total Percentage (Total Obtained Score/ 12x100)

152

CT Scan 2.11.10 Verification


Maximum Score


2.11.10.1.1 CT Scan service is open from 10 AM to 3 PM and appointments date given 1

2.11.10.1.2 Emergency CT Scan service is available round the clock 1

2.11.10.2 Adequate staffing

2.11.10.2

Adequate numbers of trained healthcare workers are available in CT scan (at least 2 staffs to cover shifts including ER) under supervision of Radiologists

1


2.11.10.3Counseling is provided to patients about radiation hazard, site and position for CT Scan and assessed for claustrophobia

1

2.11.10.4 Information education and communication materials for patients

2.11.10.4Radiation sign, appropriate Radiation awareness posters, leaflets are available in the department and OPD waiting area.

1

2.11.10.5 Adequate instruments and equipment

2.11.10.5 CT Scan Machine (at least 128 slice) available and functional at least 1 1


2.11.10.6.1CT Scan room of at least 16x20 feet with wall of at least 23cm of brick or 6cm RCC or 2mm lead equivalent and control room of 10x 12 feet

1

2.11.10.6.2 Light and ventilation are adequately maintained with help of air conditioner and exhaust fans. 1

2.11.10.6.3

The required furniture and supplies including radiation protective measures for patients,, visitors and staffs are available including magnetic gown

1

2.11.10.7 Duty rosters 2.11.10.7 Duty rosters for CT Scan service are developed

regularly and available in appropriate location. 1


2.11.10.8.1Comfortable waiting space with sitting arrangement is available for at least 5 persons in waiting lobby.

1

2.11.10.8.2 Safe drinking water is available in the waiting lobby throughout the day. 1


2.11.10.9.1CT Scan is adequately recorded as per requisition form with detail information of patients, date of Ct Scan and site and view

1

2.11.10.9.2Report have adequate information of patient, radiological diagnosis of CT Scan and checked by designated person before release

1

2.11.10.10 Information to patients

2.11.10.10 Biohazard signs and symbols are used at appropriate places 1

153


2.11.10.11.1 Radiological waste is disposed based on HCWM guideline 2014 (MoHP) 1






Postmortem 2.12.1

Components Service Standards Obtained score

Maximum Score

2.12.1.1 Physical facility

2.12.1.1.2 Designated area for mortuary room, changing room and store room and bathroom 1

2.12.1.1.2 Body dissection table (at least one) is available and used 1

2.12.1.1.3 Organ dissection table (at least one) is available and used 1

2.12.1.1.4 Adequate ventilation and light and odor management 1

2.12.1.2 Availability of postmortem services

2.12.1.2

Examination of the dead body in any unnatural death and suspicious death (Post-mortem examination or autopsy) available from 9 am to 5pm

1

2.12.1.3 Staffing 2.12.1.3

At least one MD forensic and one trained medical officer for autopsy and clinical medico-legal services

1

2.12.1.4 Supplies and instruments

2.12.1.4

Adequate supplies and instruments for forensic services (See Annex 2.12.1a Supplies and instrument for post mortem At the end of this standard)

3

2.12.1.5 Mortuary van 2.12.1.5 Mortuary van is available 24 hours (at least one) 1


2.12.1.6 Standardized medico-legal examination formats available 1


2.12.1.7.1 Staff wear mask and gloves at work. 1

2.12.1.7.2There are colored bins for waste segregation and disposal based on HCWM guideline 2014 (MoHP)

1

2.12.1.7.3 Hand-washing facility with running water and soap is available and being practiced. 1

2.7.11.4 Chlorine solution is available and utilized. 1

2.12.1.7.5 Proper disposal of anatomical waste in placenta pit after autoclaving 1



154

Annex 2.12.1a Supplies and instrument for post mortem services

S.No. Supplies and instrument Required Number Score

1. Refrigeration chamber or cool room for body preservation 8-10 bodies capacity

2. Dissection set of instruments for autopsy 2 sets

3. Magnifying lens; 20 and 40 times 1 each

4. Measuring tape 2

5. Weighing machine for organs and if possible for dead body 1

6. Camera for photography 1

7. Glass tubes for blood collection and tissue collection; reasonable numbers for regular use as per need

8. Glass slides; reasonable number for regular use as per need

9. EDTA as per need

10. Sodium Floride -200 or 500 gm As per need

11. Formalin solution as per need

12. Plastic made wide mouth containers of 500 ml capacity ; reasonable numbers for regular need as per need

13. Sodium chloride (table salt); reasonable amount for regular use as per need

14. Autopsy gown 2 sets

15. Gum boots 2 pairs

16. Gloves and masks as per need

17. Computer with printer for report preparation 1

18. Cleaning agents; soap, detergents as per need

19. Sealing materials; specific seal tape or wax seal and seal print as per need

20. Autopsy and skeletal remains SOP, Reference Manual as per need

Total score

Percentage= Total score/20 x 100


Scoring


0-50 0

50-70 1

70-85 2

85-100 3


155

Area CodeVerificationMedico-legal

services 2.12.2

Components Standards Obtained score

Maximum Score

2.12.2.1 Physical facility 2.12.2.1

Designated area for medico-legal examination with examination bed and working desk with chair

1

2.12.2.2 Availability of medico-legal services

2.12.2.2.1 Medico-legal services are available 24 hours 1

2.12.2.2.2

Injury examination and reporting in cases of physical assaults, attempted murder, sexual offenses (victim and accused), metal status examination, torture victim examination and drunkenness examination and at least one examination bed allocated for it

1

2.12.2.3 Staffing 2.12.2.3

At least one MD forensic and one trained medical officer for autopsy and clinical medico-legal services

1

2.12.2.4 Supplies and instruments

2.12.2.4.1

Adequate supplies and instruments for medico-legal services (See Annex 2.12.2a Supplies and instrument for medico legal services At the end of this standard)

3

2.12.2.4.2 Preservation of sample ensured before dispatching for test 1


Post-traumatic counseling is done to the victims of medico-legal issues like sexual offence

1


2.12.2.6 Standardized medico-legal examination formats available 1


2.12.2.7.1 Staff wear mask and gloves at work. 1

2.12.2.7.2There are well labelled colored bins for waste disposal based on HCWM guideline 2014 (MoHP)

1

2.12.2.7.3 Hand-washing facility with running water and soap is available and being practiced. 1




156

Annex 2.12.2a Supplies and instrument for clinical medico-legal services

S.No. Supplies and instrument Required number Score

1. Weight machine and height scale 1 each

2. BP set, stethoscope and torch light 1 each

3. Examination kits; sexual offence cases (rape victim examination kit) as per need

4. Gloves and masks as per need

5. Magnifying lens; 20 and 40 times 1 each

6. Measuring tape As per need

7. Camera for photography 1

8. Paper envelopes of different sizes for collection of samples and packing as per need

9. Glass tubes for collection of blood urine; reasonable number for regular use as per need

10. X ray plate view box 1

11. EDTA and Sodium floride 500 gm As per need

12. Glass slides; reasonable number for regular use as per need

13. Cupboards for store and necessary other furniture for examination room as per need

14. Sealing materials as for autopsy room as per need

15. Computer and printer for report preparation as in autopsy 1

16.

SOPs and Reference Manuals for age estimation, sexual offence case examination, injury examination, drunkenness examination, mental state examination and torture victim examination.

1

Total score



Scoring


0-50 0

50-70 1

70-85 2

85-100 3


157


One stop crisis management center

2.13

Components Service Standards Obtained Score

Maximum Score

2.13.1 OCMC coordination committee exists (multi-sectoral)

2.13.1. Quarterly meeting minute of coordination committee 1

2.13.2 Functionality of case management committee

2.13.2 Monthly meeting minute of case management committee 1

2.13.3 Timely service for patients

2.13.3.1 Prioritized services for GBV victims/survivors exits 1

2.13.3.2 Treatment for GBV survivors/affected by GBV is available 24 hours 1

2.13.4 Physical facilities for OCMC services

2.13.4

Separate space allocated for OCMC services with adequate physical facilities (See Annex 2.13a Physical facilities for OCMC At the end of this standard)

3

2.13.5 Staffing2.13.5.1

At least one Medical officer working in the hospital trained in medico-legal issues is available

1

2.13.5.2 At least two Staff nurse working in the hospital and 1 trained psycho social counselor 1

2.13.6 Timely examination from medico-legal aspects and treatment of GBV survivors/ affected by GBV

2.13.6.1

Health check-up, medico-legal examination including documentation (See Annex2.13b Instruments and supplies for treatment in OCMC At the end of this standard)

3

2.13.6.2

Preservation of samples as legal evidence done for future use (See Annex 2.13.3c Instruments and supplies for evidence collection in OCMC At the end of this standard)

3

2.13.6.3 Pregnancy test and emergency contraceptive services, tests for HIV/HBV available 1

2.13.7 Use of GBV clinical protocol

2.13.7.1 Whole site orientation on GBV clinical protocol conducted 1

2.13.7.2 Availability and use of the treatment as per the protocol and OCMC guideline 1

2.13.8 Psycho-social counselling of GBV Survivors/ affected by GBV and rehabilitation

2.13.8.1 Mental health and psychosocial counselling services available 1

2.13.8.2

If the female survivor requires to stay more days or requires advance psychosocial counseling including livelihood training, she/he shall be referred to nearby appropriate safe home/ rehabilitation centers

1

158

2.13.9 Referral services in place

2.13.9.1

Provide required referral and other services (as per the health service guideline and protocol). (Beyond health: security, legal, shelter, rehabilitation)

1

2.13.9.2 Health related referral services e.g. Safe abortion services 1

2.13.10 Information, education and empowerment for GBV survivors/ affected by GBV

2.13.10.1

Detailed information concerning the services being provided by OCMC to the survivors of GBV (Citizen charter, leaflets, community radio etc)

1

2.13.10.2Information is being given in an integrated manner ( Safe home related, OCMC, Police women children service unit)

1

2.13.11Recording and reporting

2.13.11.1

Details of the events registered in the OCMC, services (health and non-health) being provided to the survivors, listing of the referred organizations shall be documented to be classified and analyzed in due course.

1

2.13.11.2 Confidentiality shall be maintained at all stages of documentation. 1

2.13.11.3 Report to concerned authority (DCC and MoHP) in monthly report service format 1

2.13.11.4 Documentation of the current status of GBV survivors of at least last 1 year is done 1


2.13.12.1 Masks and gloves are available and used 1

2.13.12.2There are colored bins for waste segregation and disposal based on HCWM guideline 2014 (MoHP)

1

2.13.12.3 Hand-washing facility with running water and soap is available for practitioners. 1

2.13.12.4 Needle cutter is used. 1




Annex 2.13a Physical Facilities for OCMC


1 Rooms for treatment room/examination room, office and guard room 1 each

2 Toilet allocated for OCMC services as per need

3 Curtains to maintain confidentiality during the forensic examination as per need

4 Examination table 1

5 Desk 1

159

6 Chairs 3

7 Cupboard to keep clients' information with filing cabinet 1

8 Movable table lamp 1

9 toilet and bathroom for clients' use (water, bucket, mug, soap, towel) as per need

10 Hand washing facility for service provider as per need

11 Refrigerator and lockable cupboard for specimen store 1

12 Telephone 1

13 Computer and printer 1set

14 Boiler (for tea) 1 set

Total score



Scoring


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.13b Instruments and supplies for treatment in OCMC


1 Sphygmomanometer (B.P. Instrument) 1

2 Stethoscope 1

3 Torch Light 1

4 Tongue Depressor as per need

5 Tourniquet 1

6 Sterilized Gloves as required as per need

160

7 Sterilized Syringe and Needles as required as per need

8 Cotton and Bandage as required as per need

9 Sterilized Vial for sample collection as per need

10 Different sized Reflecting Mirrors (big, medium and small) 1 each

11 Sterilized Speculum 1

12 Glutaradehylde solution for high level of infection prevention as per need

13 Chlorine powder to sterilize the used materials/tools as per need

14 Protoscope /Anscope 1

15 Pregnancy Test Kit as per need

16 Specimen collection materials for communicable Sexually Transmitted Infections as per need

17 Lubricant, Clean Water, Normal Saline as per need

18 Tray for sharp instruments, such as scissors, knife etc. as per need

19 Height Measuring Scale 1

20 Weight Measuring Scale 1

Total score



Scoring


0-50 0

50-70 1

70-85 2

85-100 3


161

Annex 2.13c Instruments and supplies for evidence collection in OCMC


1 Cotton/material to collect sperm, Blood, Saliva etc. from survivor as per need

2 Container/vessel to keep the collected specimen as per need

3 Materials to swab as per need

4 Microscope slide as per need

5 Vials for blood collection as per need

6 Vials to collect urine for pregnancy test as per need

7 Paper or plastic seat as per need

8 Paper bag to hold clothes and other items as per need

9 Air spatula and slide for pap smear as per need

10 Fixing solutions: hair spray, alcohol etc as per need

11 Analgesic : Normal medications like Paracetamol, Ibuprofen etc. for pain relief as per need

12 Emergency Contraceptives: Pills and IUCD as per need

13 Thread for Suturing as per need

14 Immunization for Tetanus and Hepatitis as per need

15 STI Preventive as per need

16 Bed Sheet and Blankets for examination table as per need

17 Towel as per need

18 Clothes for Survivor (if her clothes are torn or stained). as per need

19 Gown to be worn during the examination as per need

20 Sanitary Pads and Tampons for internal use as per need

21 Documentation forms and recording forms as per need

22 Camera and Film for evidence collection 1

24 Colposcope or Magnifying Glass 1

Total score



Scoring


0-50 0

50-70 1

70-85 2

85-100 3


162

Area Code

VerificationPhysiotherapy (Physical Rehabilitation)

2.14


Maximum Score

2.14.1 Space 2.14.1Separate room for OPD physiotherapy with at least 10 physiotherapy beds with 5 exercise beds and 5 electric beds

1

2.14.2Time for patients

2.14.2.1 Physiotherapy OPD is open from 10 AM to 5 PM. 1

2.14.2.2 Inpatient physiotherapy service is available based on the requisition 1

2.14.3 Staffing 2.14.3

At least 1 physiotherapist trained in Masters in Physiotherapy (MPT), 2 trained in Bachelors in Physiotherapy (BPT),and 2 Certificate in physiotherapy (CPT) or Diploma in physiotherapy (DPT) and 1 trained office assistant treating 20 patients per day on OPD basis

1

2.14.3.1 Duty roster prepared for a month to cover 24 hours service 1

2.14.4 Maintaining patient privacy 2.14.4


1

2.14.5 Patient counseling 2.14.5

Counseling is provided to patients about the type of treatment being given and its consequences.

1

2.14.6 IEC/BCC materials 2.14.6

Appropriate IEC/BCC materials (posters, leaflets etc.) are available in the OPD waiting area.

1

2.14.7 Instruments and equipment 2.14.7

Instruments and equipment to carry out the Physiotherapy works are available and functioning (See Annex 2.14a Instruments and equipment physiotherapy At the end of this standard).

3


2.14.8.1 Adequate rooms and space for the practitioners and patients are available. 1


2.14.9 Duty rosters 2.14.9Duty rosters of OPD are developed regularly and available in appropriate location.

1



2.14.10.2 Hand-washing facilities are available for patients. 1

2.14.11 Recording and reporting 2.14.11.1 Recording and reporting throughout

treatment and follow up is done 1

163


2.14.12.1 Masks and gloves are available and used 1

2.14.12.2 There are colored bins for waste disposal based on HCWM guideline 2014 (MoHP) 1






Annex 2.14a Instruments and equipment physiotherapy

SN Instruments and equipment Required No. Score

1. Traction unit 2

2. IFT(Interferential treatment) 4

3. Ultrasound(treatment) unit 4

4. TENS (Transcutaneous nerve stimulation) 4

5. Muscle stimulator 3

6. Parallel bar 1

7. Quadriceps Table 1

8. Therabands 5

9. Heel exerciser 1

10. CPM machine knee and elbow 1

11. Physio ball 55'' 65'' and 90'' 3

12. Moist heat unit 1

13. Wax unit 1

14. Foot step 1

15. Shoulder wheel 2

16. Pulley Set 2

17. Static Cycle 1

18. Weight Cuffs set 2

19. Dumbell set 2

164

20. Shortwave diathermy 1

21. Tit table (electronic) 1

22. Microwave diathermy 1

23. Cryotherapy unit 1

24. Hand exercise table 1

25. Mobilization table / bed 2

26. Laser therapy unit 1

Total Score

Total Percentage= Total Score/26 x100


Scoring


0-50 0

50-70 1

70-85 2

85-100 3


Dietetics and Nutrition rehabilitation

2.15 Verification


Maximum Score

2.15.1 Adequate space 2.15.1 Separate space allocated for Dietetics and

Nutrition rehabilitation 1

2.15.2 Adequate time and access for patients

2.15.2.1 Dietetics and Nutrition rehabilitation unit opens from 10 am to 3 pm 1

2.15.2.2Inpatients monitored for nutritional needs, rehabilitation and therapeutic diets prescribed where needed

1

2.15.3 Adequate health workers 2.15.3

1 Senior dietitian (Masters in Nutrition & Dietetics with hospital internship, or Bachelors in Nutrition & Dietetics with one year's hospital experience), 1 dietetic assistant and 1 mid-level health workers trained in nutrition rehabilitation available for the dietetics and nutrition rehabilitation service

1

2.15.4 Maintaining patient privacy

2.15.4

Appropriate techniques have been used to ensure the patient privacy (separate rooms, curtains hung, maintaining queuing of patients, etc).

1

165

2.15.5 Patient counseling 2.15.5

Counseling is provided to patients about their nutritional status, diet prescription/ nutritional rehabilitation, use of local food as sources of the diet required and follow up

1

2.15.6 Information education and communication materials for patients

2.15.6

Appropriate IEC materials (posters, leaflets etc.) are available in waiting area on balanced diet and identification of malnutrition specially among children

1

2.15.7 Adequate instruments and equipment

2.15.7 Instruments and equipment to carry out the OPD works are available and functioning 1

2.15.8 Inpatient stabilization center for severe undernourished children with complications

2.15.8.1 Adequate space 2.15.8.1 Separate space assigned for inpatient

nutrition stabilization 1

2.15.8.2 Adequate staffing

2.15.8.2 Trained staffs assigned for inpatient nutrition stabilization 1

2.15.8.3 Adequate instrument, equipment, supplies

2.15.8.3Instruments, equipment and supplies needed for inpatient stabilization center available and functional

1


2.15.8.4 Adequate rooms and space for the practitioners and patients are available. 1


2.15.8.6 The required furniture are available 1

2.15.9 Recording and reporting 2.15.9 Treatment, follow up and progress are

recorded and reported 1



2.15.10.2 Hand-washing facilities are available for patients. 1


2.15.11.1 Masks and gloves are available. 1

2.15.11.2There are colored bins for waste segregation and disposal as per HCWM guideline 2014 (MoHP)

1






166

Area Code

VerificationCardiac catheterization Laboratory

2.16


Maximum Score

2.16.1 Time for Cardiac catheterization Laboratory (Cath Lab)

2.161.1 Routine procedures available on scheduled days 1

2.16.1.2 Emergency procedures available round the clock 1

2.16.1.3 At least two functional operating tables 1

2.16.2 Staffing 2.16.2

For one cardiac intervention, at least a team is composed of: MD Internal Medicine trained in cardiac intervention or cardiologist with one trained medical officer, two trained nursing/paramedics, and one trained office assistant

1

2.16.3 Cath Lab services available

2.16.3 Cath lab has at least following services available

2.16.3.1 Coronary Angiography 1

2.16.3.2Percutaneous transluminal coronary angioplasty/ percutaneous coronary intervention(PTCA)

1

2.16.3.3 Right heart catheterization 1

2.16.3.4 Pigtail insertion (Pericardiocentesis) 1

2.16.4 Patient counselling

2.16.4.1 Indications and reviews the clinical history and physical examination is documented 1

2.16.4.2

Informed consent is taken before intervention; patients and caretakers are given appropriate counselling about the procedure.

1

2.16.5 Patient preparation 2.16.5

Preoperative instructions for patient preparation are given and practiced with routine pre-anesthesia check up

1

2.16.6 Post-procedure care

2.16.6.1Separate area designated for post-procedure care to stabilize the patient after procedure

1

2.16.6.2

Staffs are specified for the post-procedure care including close monitoring of the vital signs and observation of patient for bleeding in intervention site

1

2.16.6.3

Adequate information shared for patient care and patient followed by at least one mid-level health worker for hand over or transfer of patient within or outside the hospital

1

167

2.16.7 Cath Lab Set Up

2.16.7.1Cath Lab has appropriate physical set up (See Annex 2.16a Physical Set Up for Cath Lab At the end of this standard)

3

2.16.7.2

General equipment, instruments and supplies available (See Annex 2.16b Furniture, Equipment, Instruments and Supplies for Cath Lab At the end of this standard)

3

2.16.7.3

Medicines and supplies available (See Annex 2.16c General Medicine and Supplies for Cath lab At the end of this standard)

3

2.16.7.4

Surgical sets for minimum list of the interventions available (See Annex 2.16d Surgical sets for Minimum list of Interventions At the end of this standard)

3

2.16.8 Safe Surgery Checklist 2.16.8 The Safe Surgery Checklist is available in

Cath Lab and used 1

2.16.9 Records 2.16.9Recording is done for all surgeries including procedure, observation during surgical procedure and complications if any

1

2.16.10 Infection prevention protocol is strictly followed by all staffs in Cath Lab

2.16.10.1 Hand hygiene 2.16.10.1

Hand-washing and scrubbing facility with running water and soap is available and being practiced with elbow tap

1

2.16.10.2 Appropriate PPE 2.16.10.2

Gowns and sterile drapes for patients and sterile gown for surgery team are available and used whenever required.

1

2.16.10.3 Fumigation 2.16.10.3 Fumigation is done at least once a week in

the Cath Lab 1

2.16.10.4 Disinfection of instruments

2.16.10.4 High Level Disinfection (e.g. Cidex) facility is available and being practiced. 1

2.16.10.5 High Dusting 2.16.10.5 High dusting is done at least twice a week

in Cath Lab 1

2.16.10.6 Appropriate segregation of waste

2.16.10.6Separate colored waste bins based on HCWM guideline 2014 (MoHP) are available and used

1

2.16.10.7 Disposal of sharps 2.16.10.7 Needle cutter is used 1

2.16.10.8 Cleaning 2.16.10.8 Chlorine solution is available and utilized for decontamination. 1


Total Percentage= Total Obtained Score/ 36 x 100

168

Annex 2.16a Physical Set Up for Cath Lab

SN Physical Set Up Score

1. Separate room designated for Cath Lab with recovery room and control room

2. Space designated for changing room for male and female staffs separately

3. Lockers for storage of the belongings of staffs

4. Separate shelves for storage of clean and dirty shoes at the entrance of the Cath Lab area demarked with red line

5. Space designated with sink facilitated with elbow tap for scrubbing

6. Designated space for tea room

7. Separate bathroom with at least one universal toilet for Cath Lab

8. Scrub basins with running water

9. Utility basins (at least 4)

Total Score



Scoring chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.16b Furniture, Equipment, Instruments and Supplies for Cath Lab

SN General Equipment and Instruments for OT Standard Quantity Score

1. Wheel chair foldable, adult size 1

2. Stretcher 1

3. Patient trolley 1

169

4. Cupboards and cabinets for store 1

5. Working desk for anesthesia, nursing station, gowning 1 each

6. OT Table- universal type/ with wedge to position patient At least 2

7. Flurosope At least 1

8. Cardiac Monitors At least 2

9. Computer with display monitor and printer in control room At least 1 set

10. Examining table 1

11. Mayo Stand with tray 2

12. Operation theatre lights 1

13. Ultra violet light source 1

14. Electronic suction machine/ Foot-operated suction machine 1/1

15. Refrigerator / cold box 1

16. Boiler/ Autoclave 1/1

17. Oxygen concentrator/ Oxygen Cylinder/ Central oxygen 1/1/ available

18. Instrument trolley 2

19. BP instrument with stethoscope 1

20. Thermometer 1

21. Steel Drum for gloves 1

22. Steel Drum for Cotton 1

23. Tourniquet, latex rubber, 75 cm 2

24. Kidney tray (600cc) 2

25. Covered instrument trays 4

26. Mackintosh sheet 1

27. Lead gown 2 sets

28. Bowl stand 2

29. Cheatle forceps in jar 2

30. Packing towel double wrapper As per need

31. Sterile gloves (6,6.5,7,7.5,8) 5 each

170

32. Towels/ eye hole As per need

33. Masks and caps As per need

34. Torch light and batteries 1 set

35. Foot steps 2

36. Wall clock 1

37. Waste bucket for scrub nurse 1

38. IV stand 2

39. Big tray, Big bowl, small bowl, kidney tray, sponge holder 2 each

40. Lap Pack At least 2

41. IV set and PMO line At least 10 each

42. Leak proof sharp container 1

43. Color coded waste bins (based on HCWM guideline 2014 (MoHP) 1 set per OT

44. Disposable syringes of different size, 3 way connector As per need

Total Score

Total percentage= Total/ 44 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.16c Medicine and Supplies for Cath Lab


1. Verapamil Injection 4 ampules

2. Heparin Injection 2 vials

3. Midazolam Injection 5 vials

4. Hydrocortisone Powder for Injection 100ml 2 vial

171

5. Frusemide Injection 2 ampules

6. Dopamine Injection 5 vials

7. Ergometrine Injection 2 ampules

8. Hydralizine injection 5 vials

9. Calcium Gluconate Injection 10ml X 2 ampules

10. Dextrose (25%/50%) Injection 2 ampules each

11. Naloxone Injection 1 ampule

12. Aminophyline Injection 2 ampules

13. Chloropheniramine Injection 2 ampules

14. Mephentine Injection 1 vial

15. IV Fluids- Ringer Lactate / Normal Saline/ DNS/ D5% 6 bottles each

16. IV infusion Set 4

17. IV Canula 22G/20G/18G 4 each

Total Score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Annex 2.16d Minimum List of Surgical Sets for Intervention


1. Catheterization set At least 5

2. Coronary angiography set At least 2

3. PTCA kit At least 2

172

4. TPI Set At least 2

5. Swan Ganz Catheter At least 2

6. Teurmo Wire J tip At least 5

7. Radial/ femoral sheath 5 Fr At least 10 each

8. Port manifold At least 10

9. Ordinary wire At least 5

10. Mersilk (2-0) cutting body As per need

11. Pigtail 5/6 Fr At least 5

Total Score

Total Percentage = Total Score/11 x 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


173

Section III: Hospital Support Services StandardsSummary Sheet for Standards and Scores


Total ScoreTotal Obtained Score (Percentage)

Central Supply Sterile Department (CSSD)

17 19

Laundry 17 19

Housekeeping 13 15

Repair, Maintenance and Power System 12 12

Water Supply 4 4

Hospital Waste Management 17 17

Safety and Security 15 17

Transportation and Communication 8 8

Store (Medical and Logistics) 7 7

Hospital Canteen and dietetics 16 16

Social Service Unit (SSU) 12 14

Total 138 148

Score of Section III


174


CSSD 3.1


Maximum Score

3.1.1 Space

3.1.1.1 Separate central supply sterile department (CSSD) is available with running water facility 1

3.1.1.2There are separate rooms designated for dirty utility, cleaning, washing and drying and sterile area for sterilizing, packaging and storage

1

3.1.2 Staffing 3.1.2 Separate staffs assigned for CSSD and is led by CSSD trained personal 1

3.1.3 Equipment and supplies for CSSD

3.1.3

Equipment and supplies for sterilization available and functional round the clock (See Annex 3.1a CSSD Equipment and Supplies At the end of this standard)

3

3.1.4 Preparing consumables 3.1.4 Wrapper, gauze, cotton balls, bandages are

prepared. 1

3.1.5 Preparing for sterilization

3.1.5.1 All used instruments are cleaned using brush chemical/detergents in a separate room. 1

3.1.5.2 All instruments and equipment are dried in a separate place 1

3.1.5.3 All instruments are packed in double wrappers 1

3.1.6 Sterilization 3.1.6

All wrapped instruments are indicated with thermal indicator and autoclaved in a separate room.

1

3.1.7 Storage 3.1.7 All sterile packs with sticker of sterilization date are stored in separate cupboards 1

3.1.8 Collection and Distribution

3.1.8.1System for single door collection and different route for distribution of the sterile supply exist and is practiced

1

3.1.8.2 Sterile supplies are distributed using basket supply system or on-demand supply system 1

3.1.9 Inventory 3.1.9 All instruments and wrappers are recorded and inventory maintained 1


3.1.10.1 Staffs use personal protective equipment at work 1

3.1.10.2There are well labelled colored bins for waste disposal based on HCWM9 guideline 2014 (MoHP)

1

3.1.10.3 Hand-washing facility with running water and liquid soap is available and being practiced. 1




9 HCWM: Health Care Waste Management

175

Annex 3.1a CSSD Equipment and Supplies

SN Items Required No. Score

1. Working Table 3

2. Trolley for Transportation 2

3. Steel Drums 10

4. Storage Shelves 2

5. Autoclave Machine (250 liter, pre-vacuum, with horizontal outlet) 2

6. Double Wrappers As per need

7. Timer 2

8. Thermal Indicator Tape As per need

9. Cap, Mask, Gown, Apron As per need

10. Gloves 1 box

11. Cotton Rolls As per need

12. Cotton Gauze As per need

13. Scissors 2

14. Gauze cutter 2

15. Buckets 5

16. Scrub Brush As per need

17. Hamper bag (cloth sack for collection of wrappers) As per need

Total Score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


176

Area Code Verification Laundry 3.2


Maximum Score

3.2.1 Space

3.2.1.1 Separate laundry room is available. 1

3.2.1.2 Separate space allocated for clean and dirty linens 1

3.2.2 Staffing 3.2.2There is a special schedule for collection and distribution of linens with visible duty roster for staffs

1

3.2.3 Equipment/ Supplies

3.2.3

Adequate equipment and supplies are available for laundry (See Annex 3.2a Equipment and Supplies for Laundry At the end of this standard)).

3

3.2.4 Segregation and decontamination of linens

3.2.4.1 Linens are segregated (soiled, unsoiled, colorful, white, blood stained) before wash 1

3.2.4.2 Separated linens are decontaminated before wash 1

3.2.5 Cleaning 3.2.5 All linens are washed using a washing machine. 1

3.2.6 Drying3.2.6.1 Space available for drying linens like

blankets in direct sunlight. 1

3.2.6.2 Linen dryer is available and used 1

3.2.7 Packing 3.2.7 All linens are ironed and packed properly. 1

3.2.8 Storage 3.2.8 Linens are properly stored in separate

cupboard. 1

3.2.9 Distribution 3.2.9

All linens are distributed using a proper method (basket supply system and on-demand supply system).

1

3.2.10 Inventory 3.2.10 All linens are recorded and inventory maintained. 1


3.2.11.1 Staff wear mask and gloves at work. 1

3.2.11.2There are well labelled colored bins for waste disposal based on HCWM10 guideline 2014 (MoHP)

1

3.2.11.3 Hand-washing facility with running water and soap is available and being practiced. 1



Percentage = Total Obtained Score/ 19 x 100

10 HCWM: Health Care Waste Management

177

Annex 3.2a Equipment and Supplies for Laundry

SN List of equipment and supplies Required No. Score

1. Working table 1

2. Ironing Table 1

3. Storage Shelves 2

4. Trolley for Transportation 2

5. Washing Machine (at least 10 kg capacity with semi/full dryer) 2

6. Iron Machine 1

7. Buckets/ Basins 5

8. Stirrer (wooden) 2

9. Boots 2 pairs

10. Cap, Mask, Gowns As per need

11. Ropes (for drying) As per need


13. House/ Utility Gloves As per need

14. Washing Powder As per need

15. Chlorine Liquid/ Powder As per need

Total Obtained Score

Total Percentage = Total Obtained Score/15 X 100


Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


178


Housekeeping 3.3


Maximum Score

3.3.1 Space for storage 3.3.1 Separate space is allocated for storage of

the housekeeping basic supplies 1

3.3.2 Staffing

3.3.2.1 Allocation of the staff for cleaning with visible duty roster 1

3.3.2.2There is checklist of cleaning in each department with contact number of assigned working personnel

1

3.3.3 Basic Supplies 3.3.3

Basic supplies are available (See Annex 3.3a Housekeeping Basic Supplies At the end of this standard)

3

3.3.4 Cleaning

3.3.4.1.1 The hospital premises are visibly clean and dust free 1

3.3.4.1.2.1 All hospital toilets are clean with no offensive smell 1

3.3.4.1.2.2 All toilets are cleaned at least three times a day 1

3.3.4.3 All doors and windows of hospital are dust-free and cleaned once a day. 1

3.3.4.4

All floors of the hospital are clean and cleaned at least twice a day (like- before registration in morning and after OPD closes)

1

3.3.4.5 All walls of the hospital are clean and are tiled or painted with enamel up to 4 feet 1

3.3.4.6 Every ward/unit must have high wash twice a month and fumigation as per need 1

3.3.5 Drainage of chlorine solution 3.3.5 Separate drainage system or pit is

maintained for drainage of chlorine solution 1

3.3.6 Garden 3.3.6 Garden and trees should cover at least 25% of the hospital premises 1



Annex 3.3a Housekeeping Basic Supplies


1. Working Table and Chair 1

2. Telephone 1

3. Housekeeping Storage Room 1

4. Shelves 2

5. Cupboards 2

179

6. Log Book for Records 1

7. Vacuum Cleaner 1

8. Sickle As per need

9. Spade As per need

10. Shovel As per need

11. Ropes As per need


13. Broom As per need

14. Buckets As per need

15. Jars As per need

16. Sprinkle Pipe As per need

17. Soaps As per need

18. Washing Powder As per need

19. Additional Bed Covers for Replacement As per need

20. Additional Pillow As per need

21. Pillow cover As per need

22. Blankets As per need

23. Personal Protective Items As per need

24. Window screens (jaali) In all windows

25. Mosquito nets As per need

26. Flower Pots As per need

Total Score



Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


180


Repair, Maintenance and Power system

3.4


Maximum Score

3.4.1 Staffing3.4.1.1

Human resource trained in biomedical engineer is designated for repair and maintenance

1

3.4.1.2 Staffs assigned to cover 24 hours shift with visible duty roster for staffs. 1

3.4.2 Preventive Maintenance

3.4.2.1Hospital has regular preventive maintenance practices (calibration, servicing of equipment) and corrective maintenance)

1

3.4.2.2 Biomedical equipment inventory of all equipment and instrument is updated 1

3.4.2.3 Separate room for storage of repairing tools and instrument 1

3.4.2.4Availability of spare parts for repair and maintenance of biomedical equipment and instruments

1

3.4.2.5 Record keeping of repair and maintenance of biomedical equipment and instruments 1

3.4.2.6 Specification of annual maintenance cost of major equipment 1

3.4.3 Availability of power sources

3.4.3.1 Hospital has main-grid power supply with three-phase line 1

3.4.3.2Hospital has alternate power generator capable of running x-ray and other hospital equipment

1

3.4.3.3 Proper inventory of fuel is maintained. 1

3.4.3.4Hospital has solar system installed (at least for essential clinical services and administrative function).

1

Standard 3.4

Total Obtained Score 12Percentage = Total Obtained Score / 12 x 100

181


Water supply 3.5

Component Standards Obtained Score

Maximum Score

3.5.1 Water supply 3.5.1

There is regular water supply system – boring or well or from drinking water supply dedicated for hospital

1

3.5.2 Water Storage

3.5.2.1Water storage tank is covered to prevent contamination and cleaned on a regular basis

1

3.5.2.2Water storage tank has the reserve capacity to supply water for two full days in case of interruptions in main water supply

1

3.5.3 Water quality 3.5.3

Water quality test is done every year and report is available as per Nepal Drinking Water Quality Standards, 2005

1

Standard 3.5




Hospital Waste Management

3.6


Maximum Score

3.6.1 Work plan prepared and implemented

3.6.1There is work plan prepared and implemented by hospital for hospital waste management

1

3.6.2 Staffing3.6.2.1 There is allocation of staff for HCWM from

segregation to final disposal 1

3.6.2.2 Whole site coaching/ orientation on health care waste management is done 1

3.6.3 Space 3.6.3There is separate area/space designated for solid waste storage and management with functional hand washing facility

1

3.6.4 Segregation of waste from source to final disposal

3.6.4Different colored bins (for risk and non-risk waste) are used from source to final disposal

1

3.6.5 Personal protection 3.6.5 Staff use cap, mask, gloves, boot, and

gown while collecting waste. 1

3.6.6 Public information

3.6.6Information regarding proper use of waste bins is displayed publicly and basic information of HCWM is displayed in hospital premises

1

3.6.7 Medication trolley with waste segregation buckets

3.6.7 Medication trolley has well labeled buckets for segregation of waste during procedures 1

182

3.6.8 Transportation of waste within the hospital

3.6.8 Hospital uses transportation trolleys separate for risk and non-risk waste 1

3.6.9 Disposal and recycle/reuse of waste

3.6.9.1 Infectious waste is sterilized using autoclave before disposal 1

3.6.9.2

Collection of recyclable/reusable items such as plastic bottles, paper, decontaminated sharps is practiced and sold to vendor/municipality

1

3.6.9.3 Composting of bio-degradable waste is practiced 1

3.6.9.4Collection of waste by the local municipality/ rural municipality after sterilization /decontamination

1

3.6.9.5Placenta pit used for disposal of human anatomical waste such as placenta, human tissue

1

3.6.9.6Biogas plant in place and energy generated used for hospital support services

1

3.6.10 Pharmaceutical and radiological waste management

3.6.10Pharmaceutical waste and radiological waste treated and disposed based on the HCWM guideline 2014 (MoHP)

1

3.6.11 Liquid waste management

3.6.11 Hospital liquid waste management is done 1

3.6.12 Waste management of electronic goods and products

3.6.12Hospital has BMET personnel to coordinate to manage waste related to electronic goods and products

1

Standard 3.6


Percentage = Total Obtained Score / 18x 100

Area CodeVerificationSafety and

Security3.7

Component Standards Obtained Score

Maximum Score

3.7.1 Staffing of security personnel

3.7.1.1 Hospital has trained security personnel round the clock. 1

3.7.1.2All security staffs are oriented with hospital codes like 001- call for help for crashing patients, 007- call for disaster in ER

1

3.7.1.3 All security staffs have participated in emergency drills 1

183

3.7.2 Office space allocated for security personnel

3.7.2 A separate office for security with communication system is available 1

3.7.3 Amenities 3.7.3

Basic amenities for safety and security are available (See Annex 3.7a Safety and Security Basic Amenities Section At the end of this standard)

3

3.7.4 Patient safety 3.7.4

The hospital has replaced all mercury apparatus with other appropriate technologies.

1

3.7.5 Continuous surveillance of hospital premises

3.7.5CCTV coverage of major areas and control under Medical Superintendent and security in-charge

1

3.7.6 Hospital has disaster mitigation system

3.7.6.1The hospital has fire extinguisher in all blocks including the fire extinguishing system

1

3.7.6.2 The hospital has installed safety alarm system including smoke detector 1

3.7.6.3 The hospital has prevented lightening by ensuring earthing system in electrification. 1

3.7.6.4Disaster preparedness orientation has been given to all staff at least every six months.

1

3.7.6.5 Exit signs are displayed to escape during disaster in all departments and wards 1

3.7.6.6 An assembly zone has been specified for disaster 1

3.7.6.7 Hospital has functional rapid response team 1

3.7.6.8 Medicine stock for post disaster response is available 1

Standard 3.7


Annex 3.7a Safety and Security Basic Amenities

SN General Items Score

1 Flash light 1

2 Whistle 1

3 List of Important Phone Numbers 1

4 Key Box 1

5 Emergency Alarm 1

6 Fire extinguisher at least one in each block 1

Obtained Score


184

Each row gets a score of 1 if all the mentioned items are available otherwise 0.

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


Area CodeVerification Transportation and

Communication3.8


Maximum Score

3.8.1 Transportation

3.8.1.1 24-hour ambulance service is available. 1

3.8.1.2 Hospital has its own well-equipped ambulance at least 2 1

3.8.1.3 The hospital has access to utility van 1

3.8.2 Communication

3.8.2.1 The hospital has telephone with intercom (EPABX) network. 1

3.8.2.2Internal communication (paging) system has been installed in all major service stations.

1

3.8.2.3 A notice board is available and being utilized. 1

3.8.2.4

List of important phone numbers including emergency contacts like ambulance, fire brigade, blood banks, hospital administration, hospital staffs is available in the reception, emergency and administration office

1

3.8.2.5There should be a public contact or information center in prime location of hospital with 24 hours staff availability

1

Standard 3.8


185

Area Code Verification Store (Medical

and Logistics)3.9


Maximum Score

3.9.1 Space 3.9.1 Separate space allocated for store for hospital- medicine and logistics 1

3.9.2 Buffer stock in medical store

3.9.2.1 A separate hospital medical store with 3 months' buffer stock is available 1

3.9.2.3Minimum and Maximum stock levels for each item are calculated and used when re-ordering stock

1

3.9.3 Inventory

3.9.3.1 Electronic database system is used in the hospital medical store. 1

3.9.3.2Hospital submits quarterly reports to LMIS utilizing either paper report or web-based (eLMIS-7)

1

3.9.4 Disposal of expired medicine 3.9.4

Disposal of expired medicine as per HCWM guideline 2014 (MoHP) is practiced in every six month

1

3.9.5 Auction of logistics 3.9.5 Auction of identified old logistics is done

annually 1




Hospital Canteen and Dietetics

3.10


Maximum Score

3.10.1 Time for patients/ visitors and staff

3.10.1 Hospital has canteen in its premises with 24 hours service 1

3.10.2 Information to patients/ visitors and staffs

3.10.2A list of food items with price list approved by Hospital Management Committee is available

1


3.10.3.1 Visibly clean floors and space allocated for cooking, cleaning and storage of stock 1


3.10.3.3 All walls of the canteen are clean and are tiled or painted with enamel up to 4 feet 1

3.10.3.4 Safe drinking water is available 24 hours 1

3.10.4 Uniform for canteen staffs 3.10.4 Dress code is maintained 1

186

3.10.5 Food for inpatients under supervision of dietetics

3.10.5.1

Staffs assigned for inpatient diet including the intensive care units and patient needing hemodialysis:Trained dietetic staff assigned for inpatient nutrition care : one Senior Dietitian (Masters qualification in Nutrition & Dietetics including hospital internship or Bachelors in Nutrition & Dietetics with 1 years hospital experience) plus one dietetic assistant per hundred general beds, plus one office assistant

Additionally, 1 senior dietitian per 25 beds for all specialized services, including ICU, NICU, PICU, nephrology/hemodialysis,

1

3.10.5.2

The inpatients who are identified needy or covered by SSU are provided with food at least four times a day and the food contains carbohydrate, fats, proteins and at least one vegetable item

1

3.10.6 IEC/ BCC materials 3.10.6

Appropriate IEC/ BCC materials (posters, leaflets, television) are available in the canteen for balanced diet

1

3.10.7 Facilities for staffs, patients and visitors

3.10.7Comfortable space with sitting arrangement is available for at least 50 people

1

3.10.8 Infection prevention and food hygiene

3.10.8.1 Separate area designated for washing dishes and visibly clean. 1

3.10.8.2There are colored bins for waste segregation and disposal based on HCWM guideline 2014 (MoHP)

1

3.10.8.3 Hand-washing facility with running water and soap is available 1

3.10.8.4 Mesh/ net to cover food and refrigerator used to store food used to cover food 1

3.10.8.5 Rat proofing and daily scrubbing of the canteen is done 1

Standard 3.10

Total Obtained Score 16Percentage = Total Obtained Score / 16x 100

Area CodeVerificationSocial Service

Unit3.11


Maximum Score


3.11.1.1 SSU open from 8am to 7pm 1

3.11.1.2 Management committee to manage 24 hours SSU services for patients 1

3.11.2 Physical facilities for SSU services

3.11.2

Separate space allocated for SSU is accessible to patients (See Annex 3.11a Physical Facilities SSU At the end of this standard)

3

3.11.3 Staffing 3.11.3 Allocation of staffs for SSU under unit chief a team of 2 to 10 facilitators 1

187

3.11.4 Identify and display target group and services covered

3.11.4Refer to ‘deprived citizen treatment fund guideline 2071’ to identify target group, and display target group and services covered

1

3.11.5 Referral mechanism in place

3.11.5.1 Referral of patients based on treatment protocol 1

3.11.5.2Documentation of referral based on ‘deprived citizen treatment fund guideline 2071’

1

3.11.5.3 SSU allocates fund for transportation for referral 1


3.11.6.1 Meetings of SSU every two months to review and discuss problems 1

3.11.6.2 Daily display of names of persons receiving free and partially free services from the unit 1

3.11.6.3Record information on free and partially free service recipients on the formats to records section of the concerned hospital

1

3.11.6.4 Prepare and submit monthly, trimester and annual report to concerned authority 1



Annex 3.11a Physical Facilities SSU


1. Separate space for SSU Available

2. Desk 2

3. Chairs 3

4. Cupboard to keep clients' information with filing cabinet 1

5. Recording and reporting forms as per need

6. Telephone 1

7. Computer and printer 1

Total Score

Percentage= Total Score / 7x 100 Each row gets a score of 1 if all the mentioned items are available otherwise 0.

Scoring Chart


0-50 0

50-70 1

70-85 2

85-100 3


188

Annex I: List of Subject Experts• Roshani Laxmi Tuitui, Chief, Hospital Nursing Administrator, MoHP• Dr Roshan Neupane, Chief Medical Superintendent, Myagdi District Hospital• Dr Chuman Lal Das, Chief Medical Superintendent, Sagarmatha Zonal Hospital • Ramkrishna Lamichhane, Under-Secretary, CSD/ MoHP• Sangita Shah, Senior Drug Administrator, QARD, MoHP• Krishna Subedi, Section Officer, CSD/MoHP • Shrijana Shrestha, Chief, Environmental Health and HCWM Section, MD, DoHS• Dr Runa Jha, Pathologist, National Public Health Laboratory, MoHP• Uma Kumari Rijal, Nursing Officer, MoHP• Bijaya Kranti Shakya, Sr. PHO, QARD, MoHP• Kopila Shrestha Palikhey, Nursing Director, TUTH• Dr Asha Thapa, Dental Surgeon, NAMS • Dr Bhaskar M. M. Kayastha, Dermatologist, NAMS • Dr Dhundi Paudel, ENT/ Audiologist, NAMS• Dr Ravi Ram Shrestha, Chief Consultant Anesthesiologist, NAMS• Dr Rajiv Jha, Neurosurgeon, NAMS• Dr Saroj Sharma, Consultant Radiologist, NAMS • Dr Peeyush Dahal, Consultant Burn/Plastic Surgeon, NAMS• Dr Ashish Shrestha, Consultant Physician, PAHS • Dr Rajesh Gangol, Palliative care specialist, PAHS• Dr Ramesh Kandel, Consultant Geriatrician, PAHS• Dr Nabees Man Singh Pradhan, Consultant Orthopedics, PAHS • Dr Sanjay Paudel, Consultant Surgeon, PAHS • Dr Anil Baral, Consultant Nephrologist, NAMS• Dr Shanta Bir Maharjan, Consultant Surgeon, PAHS• Mohan Poudel, Housekeeping and Laundary Incharge, PAHS • Devi Shah, CSSD Incharge, PAHS • Dr Ananta Adhikari, Psychiatrist, Patan Mental Hospital• Dr Jageshowor Gautam, Director, Paropakar Maternity and Women's Hospital• Asha Laxmi Prajapati, Nurse, Paropakar Maternity and Women's Hospital • Dr Archana Amatya, Obstetrician and Gynecologist, TUTH/IOM • Dr Harihar Wasti, Medico-legal Expert, TUTH/IOM• Dr Ramesh Kumar Maharjan, Emergency Physician, TUTH/IOM • Dr Ratna Mani Gajurel, Cardiologist, Manmohan Cardiovacular and Throcic Centre, TUTH/ IOM • Dr Rakesh Verma, Urologist, Human Organ Transplant Center • Subhadra Regmi, Hemodialysis Nurse, Human Organ Transplant Center • Dr Amir Neupane, Physiotherapist, AASHAH Health Care • Dr Ben Limbu, Ophthalmologist, Til Ganga Eye Hospital • Amit Kumar Shah, Radiographer, District Hospital Dhankuta• Ambika Thapa, Technical Coordinator for MSS, MoHP, WHO Nepal/NSI/NHSSP

189

Annex II: List of Reviewers• Dr Krishna Kumar Rai, Technical Advisor to Minister of Health and Population• Dr Sushil Nath Pyakurel, Chief Specialist, MoHP• Dr Guna Raj Lohani, DG, DoHS• Narayan Prasad Dahal, DG, DDA• Dr Vasudev Upadhyaya, DG, DoA• Santa Bahadur Shrestha, Former Secretary of MoHP• Dr Taranath Poudel, Medical Generalist, MoHP• Dr Dipendra Raman Singh, Chief, QARD, MoHP (Chief, The Then CSD, MoHP)• Dr Bhim Singh Tinkari, Chief, The then PHAMED, MoHP• Mohammad Daud, Chief, Federalism Implementation Unit, MoHP• Dr Bikash Devkota, Chief, Management Division, DoHS, MoHP• Dr Madan Kumar Upadhyaya, Executive Director, Health Insurance Board• Mahendra Shrestha, Advocacy Officer to Minster of Health and Population• Roshani Laxmi Tuitui, Chief, Hospital Nursing Administrator, MoHP• Dr Roshan Neupane, Chief Medical Superintendent, Myagdi District Hospital• Dr Chuman Lal Das, Chief Medical Superintendent, Sagarmatha Zonal Hospital • Ramkrishna Lamichhane, Under-Secretary, The Then CSD/ MoHP• Sangita Shah, Senior Drug Administrator, QARD, MoHP• Krishna Subedi, Section Officer, The Then CSD/MoHP • Shrijana Shrestha, Chief, Environmental Health and HCWM Section, MD, DoHS• Dr Arjun Sapkota, Chief, The then Quality Section, MD, DoHS • Dr Basudev Pandey, Director NCASC, DoHS• Dr Runa Jha, Pathologist, National Public Health Laboratory, MoHP• Dr Punya Paudel, The then FHD, DoHS• Uma Kumari Rijal, Nursing Officer, MoHP• Bijaya Kranti Shakya, Sr. PHO, QARD, MoHP• Dipak Raj Bhatta, PHI, DoHS• Krishna Shrestha, NHTC, DoHS• Kopila Shrestha Palikhey, Nursing Director, TUTH• Dr Asha Thapa, Dental Surgeon, NAMS • Dr Bhaskar M. M. Kayastha, Dermatologist, NAMS • Dr Dhundi Paudel, ENT/ Audiologist, NAMS• Dr Ravi Ram Shrestha, Chief Consultant Anesthesiologist, NAMS• Dr Rajiv Jha, Neurosurgeon, NAMS• Dr Saroj Sharma, Consultant Radiologist, NAMS • Dr Bhupendra Basnet, Director, Bir Hospital• Dr Ganesh Rai, Director, Kanti Children's Hospital • Dr Dilip Sharma, Registrar, Nepal Medical Council • Dr Ganesh Shah, Consultant Pediatrician, PAHS • Dr Ashish Shrestha, Consultant Physician, PAHS • Dr Bishnu Prashad Sharma, Director, PAHS• Dr Arjun Acharya, Director, WRH, Pokhara• Dr Rajesh Gangol, Palliative care specialist, PAHS• Dr Ramesh Kandel, Consultant Geriatrician, PAHS• Dr Nabees Man Singh Pradhan, Consultant Orthopedics, PAHS • Dr Sanjay Paudel, Consultant Surgeon, PAHS • Dr Shanta Bir Maharjan, Consultant Surgeon, PAHS• Mohan Poudel, Housekeeping and Laundary Incharge, PAHS • Devi Shah, CSSD Incharge, PAHS • Dr Ananta Adhikari, Psychiatrist, Patan Mental Hospital• Dr Jageshowor Gautam, Director, Paropakar Maternity and Women's Hospital• Asha Laxmi Prajapati, Nurse, Paropakar Maternity and Women's Hospital • Dr Archana Amatya, Obstetrician and Gynecologist, TUTH/IOM • Dr Harihar Wasti, Medico-legal Expert, TUTH/IOM

190

• Dr Ramesh Kumar Maharjan, Emergency Physician, TUTH/IOM • Dr Ratna Mani Gajurel, Cardiologist, Manmohan Cardiovacular and Throcic Centre, TUTH/ IOM • Dr Rakesh Verma, Urologist, Human Organ Transplant Center • Subhadra Regmi, Hemodialysis Nurse, Human Organ Transplant Center • Dr Amir Neupane, Physiotherapist, AASHAH Health Care • Dr Ben Limbu, Ophthalmologist, Til Ganga Eye Hospital • Dr Mukti Shrestha, Chairperson, Nepal Medical Association• Dr Prakash Budhathoky, Sr. Dental Surgeon, NAMS; Treasurer, Nepal Medical Association• Raj Kumari Gyawali, Nursing Association of Nepal• Amit Kumar Shah, Radiographer, District Hospital Dhankuta• Dr Amrit Pokhrel, Medical Superintendent, Syanjga District Hospital• Dr Shilu Aryal, Obgyn Expert• Kabiraj Khanal, NHSSP• Dr Indira Basnet, NHSSP• Dr Sushil Chandra Baral, NHSSP• Dr Kishori Mahat, NHSSP• Ghanshyam Gautam, NHSSP• Pradeep Paudel, NHSSP • Dr Maureen Dar lang, NHSSP• Kamala Shrestha, NHSSP• Dr Anil Bahadur Shrestha, Executive Director, NSI• Dr Kashim Shah, NSI• Rita Pokhrel, NSI• Ian Chandwell, NSI• Balsundar Chashi, NSI• Bijay Dhakal, NSI• Janardhan Pathak, NSI• Jot Narayan Patel, NSI• Sushma Lama , NSI • Sharada Shah , NSI• Prashanta Vikram Shahi, NSI• Dr Meera Upadhayaya, WHO Nepal• Kimat Adhikari, WHO Nepal• Anjana Rai, WHO Nepal• Ambika Thapa, Technical Coordinator for MSS, MoHP, WHO Nepal/NSI/NHSSP

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